1IBRARY OF CONGRESS, 
- ■5SS&—- 

ShdfJ§&5 



UNITED STATES OF AMERICA. 



TREATISE ON DISLOCATIONS 






BY 



LEWIS A. STIMSON, B.A., M.D., 

PROFESSOR OF CLINICAL SURGERY TN THE UNIVERSITY OF THE CITY OF NEW YORK ; SURGEON 

TO THE NEW YORK, PRESBYTERIAN, AND BELLEYUE HOSPITALS,* MEMBER OF THE 

NEW YORK SURGICAL SOCIETY: CORRESPONDING MEMBER OF THE 

societe'de CHIRURGIE OF PARIS. 



With One Hundred and Sixty-three Illustrations. 








PHILADELPHIA: 

LEA BROTHERS & CO. 

1888. 



Entered according to the Act of Congress, in the year 1888, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress, at Washington. All rights reserved. 



doesas, print: 
philadelphia, 



PREFACE. 



The interval of nearly five years that has elapsed between the publi- 
cation of the volume on Fractures and the completion of this one on 
Dislocations is longer than was anticipated, and the delay is in the 
main due to the great amount of material that had to be collected and 
examined in the preparation of the work. The Index Ifedicus, the 
Index Catalogue of the Surgeon-General's Library, the encyclopaedias, 
and the greatly multiplied text-books on surgery and periodicals con- 
tain or give references to a number of reported cases vastly in excess 
of those that have heretofore been within the reach of writers ; and 
while this has greatly facilitated the search for cases, it has also rendered 
necessary a corresponding amount of labor to collect and utilize the 
material. An effect of this increase in the amount of material appears 
in the accounts given of the rarer forms of injury, of some of which I 
have been able to give systematic descriptions, instead of simply quoting 
the one or two cases which have heretofore embodied all that was 
known upon the subject. 

So far as possible, I have always gone to original reports, and have 
subjected them to careful scrutiny: this has resulted in the rejection of 
some cases, and in the transfer of others to different groups. A number 
of errors^some of them of long standing and wide circulation — have 
thus been corrected, some of which arose through reliance upon incom- 
plete or faulty abstracts or reports, and others through faulty diagnoses 
which have been corrected by the aid of post-mortem examination or 
by critical review of the history in the light of later researches and 
accumulated evidence. When the scantiness of the report or the use of 
ambiguous terms has left some detail in doubt I have never given my 
own interpretation, except as such, and have usually quoted the 
reporter's description literally. This, of course, has required the 



VI PREFACE. 

transfer to these pages of the ambiguity of the original reports, but I 
have deemed this preferable to the introduction of unexplained changes 
or substitutions, however justifiable they might seem. 

In the classification of the different forms I have sought, while 
avoiding the introduction of new terms, to group them in a few large 
classes characterized by some feature of importance in reduction, and to 
mark the variations by subdivision of these classes ; the distinguishing 
feature of a class has usually been the direction of the primary displace- 
ment, and it is also usually indicated in the name given to the class, 
while the names of the subdivisions have been derived from the 
secondary displacements or from the newly established relations of 
the dislocated bone. 

A special effort has been made to secure accuracy in the references 
given in foot-notes, and while I cannot hope that errors in transcribing 
and printing have been entirely escaped or corrected, yet I believe them 
to be but few, and that, practically, all the references that I have been 
able to verify — those given here without quoted authority — will be 
found correct. 

LEWIS A. STIMSON. 



34 East Thirty-third St., New York, 
April, 1888. 



CONTEXTS. 



PART I. 

TRAUMATIC DISLOCATIONS. 



CHAPTER I. 

GENERALITIES. 

Definitions 17 

Statistics 20 



CHAPTER II. 



ETIOLOGY AND MECHANISM. 



a. Predisposing causes . . . .24 

b. Immediate or determining causes 25 

Recurrent or habitual dislocations .27 



CHAPTER III. 

PATHOLOGICAL ANATOMY IX RECENT DISLOCATIONS; COMPLICATIONS; 
PROCESS OF REPAIR AFTER REDUCTION. 

Complications 30 

Bones 31 

Bloodvessels .33 

Nerves 35 

Viscera 38 

Soft parts and integument 39 

Repair 40 



CHAPTER IV. 

PATHOLOGY OF UNREDUCED ( ANCIENT) DISLOCATIONS . 43 



Vlll 



CONTENTS. 



CHAPTER V. 

SYMPTOMS AND DIAGNOSIS. 

PAGE 

Objective signs . . . . . . ... . . . . 50 

Deformity . . . 50 

Loss of mobility . . . 52 

Crepitation 53 

Subjective symptoms ... . . . . . . . . .53 

Pain . ■ . . . .53 

Loss of function ; history ......... 54 



CHAPTER VI. 



COURSE AND PROGNOSIS 



56 



CHAPTER VII. 

TREATMENT. 

Spontaneous reduction .......... 59 

Obstacles to reduction . . . . . ... . . .61 

Anaesthesia . . . . . . . . . . .63 

History of methods of reduction 65 

After-treatment ....... ..... 72 

Habitual dislocation 73 



CHAPTER VIII. 



ACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE A 
DISLOCATION. 

Integument .... 

Emphysema of the cellular tissue 

Rupture of the muscles 

Avulsion of a portion of a limb 

Injuries of the main bloodvessels 

Injuries to nerves 

Fracture ..... 

Inflammation, suppuration, gangrene 

Persistent oedema .... 

Syncope and sudden or early death ; fat embolism 



74 

75 
76 
77 
78 
79 
89 
91 
93 
94 
95 



CONTENTS 



PAET II 



NON-TRAUMATIC DISLOCATIONS 







CHAPTER IX. 








CONGENITAL DISLOCATIONS. 


PAGE 


Statistics 






. 97 


Etiology 






. 88 


Pathology . 






. 103 


Symptoms ar 


id diagnosis . 


.106 


Treatment . 






. 108 



CHAPTER X. 

SPONTANEOUS DISLOCATIONS . . . .111 

By distention 112 

Paralytic . . . Ill 

Voluntary . 115 

By destruction ; by deformity 115 



PAET III. 

SPECIAL DISLOCATIONS, 

CHAPTER XI. 



DISLOCATIONS OF THE LOWER JAW. 



Backward with fi 

Forward 

Pathology 
Symptoms 
Treatment 

Pathological 

Congenital . 



actur< 



117 
119 
120 
122 
123 
126 
127 



CONTENTS. 



CHAPTEE XII. 



DISLOCATIONS OF THE VERTEBRAE AND OF THE OCCIPUT FROM 
THE ATLAS 

Classification and pathology 
Etiology, symptoms, and diagnosis 

Prognosis 

Treatment . . . . 

Dislocations of the occiput 

Dislocations of the atlas 

Dislocations of the lower six cervical vertebrae 

Dislocations of the dorsal vertebras . 

Dislocations of the lumbar vertebra? . 



128 

131 
13? 
140 
141 
143 
145 
149 
157 
159 



CHAPTEE XIII 



DISLOCATIONS OF THE STERNUM. 



Of the body from the manubrium 
Of the ensiform process 



161 

165 



CHAPTEE XIV. 

DISLOCATIONS OF THE RIBS AND COSTAL CARTILAGES. 

Of the head of the rib . . . 167 

Of the ribs from the costal cartilages . . . . ' . . . 169 

Of the costal cartilages from the sternum . 170 

Of one cartilage upon another . . . . . . . . .171 



CHAPTEE XV. 



DISLOCATIONS OF THE CLAVICLE 



A. Of the sternal end 

Forward . 
Backward 
Upward . 

B. Of the acromial end 

Supra-acromial 
Subacromial . 
Subcoracoid . 

C. Simultaneous of both ends 



173 

174 
175 
179 
182 
184 
185 
191 
193 
194 



CONTENTS. 



XI 



CHAPTER XVI. 

DISLOCATIONS OF THE SHOULDER. 

PAGE 

Anatomy 196 

Statistics 200 

Classification ■ 202 

Anterior (and downward) dislocations 207 

1. Subcoracoid 207 

Pathology 211 

Symptoms and diagnosis 214 

2. Intracoracoid . . . ... . . . . . 217 

Treatment of anterior dislocations 219 

Direct reposition ; traction downward and outward . . . 222 

Traction upward 224 

Traction with leverage . 225 

Heel in the axilla 22(3 

Forcible traction 227 

Manipulation 227 

After-treatment 232 



CHAPTER XVII. 



dislocations OF the shoulder — Continued. 

Downward dislocations (subglenoid) . 

Symptoms ; treatment ..... 

Luxatio erecta 

Subtricipital dislocation .... 
Posterior dislocations (subacromial, subspinous) 

Symptoms 

Treatment 

Upward dislocations (supracoracoid, supraglenoid) 



234 

237 
237 
239 
240 
245 
247 
248 



CHAPTER XVIII 



dislocations of the shoulder — Continued. 



Associated injuries and complications 
Prognosis and after-treatment 

Habitual dislocation 
Treatment of old dislocations 

Subcutaneous section . 

Arthrotomy . 

Excision of the head of the humerus 

Fracture of the surgical neck 
Congenital dislocations ... 
Pathological dislocations and subluxations 
Dislocations due to paralysis 



253 
261 
262 
266 
267 
268 
269 
270 
271 
276 

978 



Xll 



CONTENTS. 



CHAPTEE XIX. 



DISLOCATIONS OF THE ELBOW. 



Anatomy .... 

Classification 

Dislocations of the forearm back 

Pathology 

Complications 

Symptoms . 

Treatment . 
Lateral dislocations 

Incomplete lateral 

A. Inward . 

B. Outward . 
Complete, outward 

Forward dislocations . 
Divergent dislocations of tl 



ward 



e radius and ulna 



28a 

28a 

285 
287 
290 
291 
294 
298 
299 
301 
302 
306 
310 
315 



CHAPTEE XX. 



DISLOCATIONS AT THE ELBOW 



Dislocation of the ulna alone 
Dislocation of the radius alone . 

1. Backward .... 

2. Outward ..... 

3. Forward 

4. By elongation, or subluxation in children 
Dislocation of the head of the radius, with fracture of the ulna 



— Continued. 



319 

323 
324 
328 
331 
335 
340 



CHAPTEE XXI. 

DISLOCATIONS OF the ELBOW— Continued. 

Treatment of old dislocations . . . . . . . . 343 

Congenital and pathological dislocations 349 

CHAPTEE XXII. 

DISLOCATIONS AT THE WRIST. 

A. Dislocations of the lower radio-ulnar joint 353 

B. Dislocations of the radio-carpal joint . . . . . . . 356 

Backward 357 

Forward ........... 361 

Outward 362 



CONTENTS. Xlll 

PAGE 

Pathological 363 

Congenital 366 

C. Dislocations of the carpal bones 367 

Medio-carpal 368 

Scaphoid 369 

Semilunar 370 

Unciform ; pisiform ; os magnum . . . . . . . 372 

Trapezoid ; trapezium .......... 373 

Os magnum and trapezoid 374 

D. Carpo-metacarpal dislocations . . . . 374 



CHAPTER XXIII. 

DISLOCATIONS OF THE THUMB AND FINGERS. 

Proximal phalanx of thumb 380 

Anatomy 381 

Backward 382 

Forward . 388 

Metacarpophalangeal of the fingers 389 

Dislocations of the middle phalanges 391 

Distal phalanges 392 



CHAPTER XXIV, 



DISLOCATIONS OF THE PELVIS AND OF COCCYX. 

Dislocation of the pelvis 394 

Coccyx 395 



CHAPTER XXV. 

DISLOCATIONS OF THE HIP. 

Anatomy 397 

Statistics 401 

Simultaneous dislocation of both hips 402 

Compound dislocations 402 

Classification 404 

Backward dislocations 408 

1. Dorsal dislocations 409 

Causes 409 

Pathology .410 

Symptoms 414 

Diagnosis . . . 417 



XIV CONTENTS. 

PAGE 

2. Everted dorsal dislocations . 418 

Pathology 420 

Anterior oblique . . . . . . . . . . . 421 

Symptoms . . 422 

Treatment . . . . . . . .• . . . 423 



CHAPTEE XXVI. 

DISLOCATIONS OF the hip — Continued. 

Dislocations downward and inward . " 428 

1. Obturator dislocations ......... 428 

Pathology 429 

Symptoms 431 

Treatment . . . . 433 

2. Perineal dislocations . . . . 435 

Dislocations forward and upward or inward (suprapubic) . . . 435 

Pathology . . . . . .436 

Symptoms 438 

Treatment 440 

Dislocations directly upward ... 441 

Dislocations downward (infracotyloid) ....... 446 



CHAPTEE XXVII. 

dislocations OF the hip — Continued. 

Complications 449' 

Accidents caused by attempts to reduce . 454 

Prognosis and after-treatment . . . . . . . . . 455 

Habitual dislocations 455 

Treatment of old unreduced dislocations . . . . . . 457 

Spontaneous or pathological dislocations . 463 



CHAPTER XXVIII. 

DISLOCATIONS of the knee. 

Anatomy 467 

Statistics . ■ 469 

Dislocations forward 469 

Dislocations backward 473 

Lateral dislocations ........... 476 

A. Outward dislocations 476 

B. Inward dislocations . 479 

Antero-lateral dislocations 479 



CONTENTS. XV 



Dislocations by rotation 480 

Dislocation of the semilunar cartilages . 482 

Congenital dislocations . . . . 486 

Spontaneous or pathological dislocations . 488 



CHAPTEE XXIX. 

DISLOCATIONS OF THE PATELLA. 

General considerations 490 

Outward dislocations . . . . . . . . . . 493 

1. Complete. . . . . 493 

2. Incomplete 496 

3. Outward edgewise, or vertical . . . . . . . 497 

4. Complete reversal . . . 498 

Inward dislocations 498 

Congenital dislocations . . . .'.-..' 500 

Spontaneous or pathological dislocations 501 



CHAPTER XXX. 

DISLOCATIONS OF THE FIBULA. 

A. Dislocations of the upper end 503 

B. Dislocations of the lower end . . . . . . . . 506 

Spontaneous or pathological dislocations 506 



CHAPTER XXXI. 

DISLOCATIONS AT OR NEAR THE ANKLE. 

Anatomy 508 

1. Dislocation of the foot. Tibio-tarsal dislocations ..... 509- 

A. Dislocations backward . . . 509 

B. Dislocations forward 511 

C. Dislocations inward 513 

D. Dislocations outward 514 

E. Compound and complicated dislocations . . . . 515 

2. Subastragaloid dislocations 516 

A. Dislocations inward or inward and backward . . . .516 

B. Dislocations outward . 518 

C. Dislocations backward 519 

D. Dislocations forward 520 

Diagnosis 520 

Treatment 521 

3. Total dislocations of the astragalus 522 

A. Forward 522. 



XVI 



CONTENTS 



PAGE 

B. Outward and forward 523 

C. Inward and forward . 523 

D. Backward . . '.."-. . , . . . . . .523 

E. By rotation. . . . ... . . . . . 525 

Treatment 528 

4. Medio-tarsal dislocations 529 

Congenital dislocations of the ankle-joint ....... 530 



CHAPTER XXXII 



DISLOCATIONS OF THE TARSAL AND METATARSAL BONES AND OF THE TOES. 



Calcaneum . . 


. 531 


Scaphoid ........... 


. 531 


Cuboid 


. 531 


Cuneiform bones 


. 532 


Of the metatarsal bones from the tarsus and from one another . 


. 532 


Dislocations of the toes . . ■ 


. 534 


A. Metatarsophalangeal dislocations . . 


. 534 


1. Of the great toe 


. 534 


2. Of the other toes ....... 


. 534 


B. Dislocations of the phalanges 


. 534 



LIST OF ILLUSTRATIONS. 



1. Recurrent or habitual dislocation of the shoulder, showing the open- 

ing into the subacromial bursa 41 

2. Old supracotyloid dislocation of the femur, with very complete new 

acetabulum 

3. Scapula showing new socket formed in an old unreduced subcoracoid 

dislocation 

4. Old unreduced dislocation of the right humerus, with interposition 

of the capsule 

5. Diagram to show the effect of position upon the apparent length o 

the arm in dislocation of the shoulder 

6. Diagram to show the action of a ligament in limiting the range of 

motion in a dislocation 

7. Diagram to illustrate the action of an untorn ligament or portion of 

capsule in opposing reduction 

8. Jarvis's adjuster 

9. Section through the Y cartilage of the acetabulum into the obturator 

foramen 

10. Congenital dislocation of the head of the radius upward and forward 

with exaggerated growth in length 

11. Left hip of an eight months foetus with double dislocation 

12. The femur of the same, divided longitudinally . . 

13. Double congenital, subacromial dislocation 

14. Congenital dislocation of the left elbow 

15. Unilateral congenital dislocation of the hip .... 

16. Double congenital dislocation of the hip 

17. Nelaton's specimen of dislocation of the lower jaw in which the coro- 

noid process was caught below the malar bone 

18. Diagrammatic of the external lateral ligament of the lower jaw 

19. Bilateral dislocation of the lower jaw . . . . 

20. Dislocation of the jaw of long standing . . . . . 

21. Stromeyer's forceps 

22. Congenital dislocation of the lower jaw 

23. Cervical vertebra 

24. Dorsal vertebra 

25. Direction of the median axis in the different sections of the spinal 

column 

26. Complete unilateral dislocation by rotation or abduction; cervical 

vertebra 

27. Dislocation of the neck by flexion ; median section ... 



45 

45 

47 

52 

52 

62 
71 

102 

103 
104 
104 
105 
106 
107 
107 

120 
121 
122 
123 
125 
126 
130 
130 

131 

132 
151 



28. Bilateral dislocation by flexion ; fourth cervical vertebra ; from behind 152 



XV111 



LIST OF ILLUSTRATIONS. 



FIG. 

29. Bilateral dislocation by flexion ; fourth cervical vertebra ; from the 

left side 

30. Complete unilateral dislocation by rotation or abduction . 

31. Ayre's case of bilateral dislocation forward of the fifth cervical vertebr 

32. Frontal section through the sterno-clavicular joint 

33. Recamier's dressing for fractured clavicle . 

34. Dislocation upward of the sternal end of the clavicle 

35. Ligaments uniting the clavicle to the scapula 

36. Complete supra-acromial dislocation of the clavicle 

37. Showing the relations of the humerus and scapula 

38. Horizontal section through the shoulder-joint 

39. The shoulder-joint; from in front 

40. The interior of the shoulder-joint from behind . 

41. Showing the range of positions that may be taken by the head of the 

humerus after primary displacement forward or downward 

42. Subcoracoid dislocation, reduced ...... 

43. Subcoracoid dislocation on a cadaver . . . . . 

44. Subcoracoid dislocation ; the bones ..... 

45. Scapula showing new socket formed in an old unreduced subcoracoid 

dislocation 

46. Subcoracoid dislocation ; showing the different degrees of rotation of 

the humerus in different positions . 

47. Old unreduced dislocation of right humerus, with interposition of the 

capsule . . . . . . . . . 

48. Reunited fracture of the greater tuberosity of the humerus 

49. Subcoracoid dislocation of the left shoulder 

50. Subcoracoid dislocation 

51. Diagram to show the effect of position upon the apparent length of 

the arm in dislocation of the shoulder ..... 

52. Intracoracoid dislocation, with arm fixed in horizontal abduction 

53. Reduction by traction ; fixation of scapula . 

54. Reduction by vertical traction 

55. Reduction by the knee in the axilla . . 

56. Reduction by the heel in the axilla 

57. Reduction with the pulleys ........ 

58. Collin's instrument for reduction of dislocation of the shoulder 

59. Kocher's method of reduction by manipulation ; 1st movement, out 

ward rotation . . . . . . . . . . 

60. Kocher's method of reduction ; 2d movement, elevation of elbow 

61. Kocher's method of reduction; 3d movement, inward rotation and 

lowering of elbow ...... 

62. Subglenoid dislocation ...... 

63. Subglenoid dislocation 

64. Subspinous dislocation of the shoulder 

65. Supracoracoid dislocation ..... 

66. Supracoracoid dislocation ; Busch's case 

67. Horizontal section of the head of the humerus in Cramer's 

habitual dislocation ........ 



of 



264 



LIST OF ILLUSTRATIONS. XIX 

FIG. PAGE 

68. R. W. Smith's case of double congenital subcoracoid dislocation of 

the shoulder ; scapula of left side 271 

69. The same; left humerus 271 

70. The same ; right scapula 272 

71. The same ; right humerus 272 

72. Double congenital, subacromial dislocation ..... 273 

73. R. W. Smith's case of double congenital subacromial dislocation of 

the shoulder ; right humerus 274 

74. The same . left humerus 274 

75. The bones of the elbow . . 281 

76. New formation of bone in an unreduced dislocation of the elbow 

backward 288 

77. Dislocation of the elbow backward 291 

78. Reduction of dislocation of the elbow backward .. . . . 295 

79. Showing the extent of separation of the bones necessary in reduction 

with the elbow at a right angle 295 

80. Old incomplete dislocation inward ; Broca's case .... 301 

81. Incomplete outward dislocation 303 

82. Complete outward dislocation 309 

83. Complete outward dislocation of the elbow 309 

84. Forward dislocation of the elbow ; Canton's case .... 312 

85. Dislocation of ulna alone backward, first form 320 

86. Dislocation of the ulna alone backward ; inner side .... 322 

87. The same ; outer side 322 

88. Dislocation of the head of the radius backward .... 327 

89. Dislocation of the head of the radius outward 329 

90. Hilton's case of dislocation of the head of the radius forward . . 332 

91. Subluxation of the head of the radius 338 

92. New formation of bone in an old unreduced dislocation . . . 346 

93. Dislocation of the head of the radius upward in consequence of arrest 

of development of the ulna = ....... 349 

94. Congenital dislocation of the left elbow 350 

95. 96. Allen's case of congenital dislocation of the elbow . . . 350 

97. Fracture of the radius and ulna 355 

98. Dislocation of the carpus backward ....... 359 

99. Dislocation of the wrist backward, and Colles's fracture of the radius 360 
100, 101. Madelung's case of spontaneous dislocation of the carpus forward 364 

102. Bones of the wrist ; posterior aspect 367 

103. The metacarpophalangeal joint of the left thumb . . . . 381 

104. 105. Incomplete dislocation of the thumb 382 

106, 107. Simple complete dislocation of the thumb .... 383 

108, 109. Simple complete dislocation of right thumb .... 384 

110, 111, 112. Complex dislocation of thumb 384 

113. Farabeuf's instrument for reduction of dislocation of tlie thumb . 386 



114. Levis's instrument for making traction in reduction of d 

of the phalanges 

115. Faulty method of use of Levis's instrument 

116. Position of sesamoid bones during- forcible traction . 



slocations 



386 
387 
387 



117. Interposition of the sesamoid bones by premature flexion . . 387 



XX LIST OF ILLUSTRATION'S. 



118. The ilio-femoral, or Y-ligament 398 

119. Relations of the head of the femnr and the obturator interims . . 399 

120. The left hip-bone viewed from a point directly opposite the aceta- 

bulum . " . . . . 407 

121. Morris's case of dorsal dislocation . ... . . . 411 

122. Dislocation below and then behind and above the obturator internus 412 

123. Dorsal dislocation below the obturator internus 413 

124. Dorsal dislocation . . . . . . . . . . . 413 

125. Eecent dorsal dislocation 414 

126. Dorsal dislocation 414 

127. Dorsal dislocation below and then behind the obturator internus . 415 

128. Dorsal dislocation . . . . . . . ... . 415 

129. Dorsal dislocation below the tendon 416 

130. Dorsal dislocation downward and outward toward the tuberosity . 416 

131. Old everted dorsal dislocation . . •'■'.'■ . . . 421 

132. Supraspinous dislocation . 422 

133. 134. Anterior oblique dislocation . . . . . . 422 

135. Anterior oblique dislocation . 423 

136. Everted dorsal dislocation . . . ... . . . 423 

137. Obturator dislocation, showing rent in the capsule . . . . 430 

138. Old obturator dislocation 430 

139. Obturator dislocation 431 

140. 141. Obturator dislocation 432 

142. Reduction of obturator dislocation by rotation and circumduction 

inward 433 

143. The same, showing the mechanism of the manoeuvre . . 434 

144. Old obturator dislocation of the left hip 434 

145. Old unreduced suprapubic dislocation of the hip .... 438 

146. Ilio-pectineal dislocation . . . . . . •■'.', . 439 

147. Suprapubic dislocation 439 

148. Gely's case of old supracotyloid dislocation ..... 442 

149. Milner's case of supracotyloid dislocation 443 

150. Infracotyloid dislocation . . . 447 

151. MacCormac's case of old obturator dislocation 458 

152. Dislocation of the knee forward . 471 

153. Robert's case of dislocation of the knee outward, with abduction . 478 

154. 155. Marsh's clamp for the treatment of dislocation of the semi-lunar 

cartilages 486 

156. Congenital dislocation of the knee . 487 

157. Diagram of the various dislocations of the patella .... 492 

158. Complete dislocation of the patella outward ..... 493 

159. Andrew's case of dislocation of the patella outward .... 494 

160. Dislocation of the patella outward 495 

161. 162. Subastragaloid dislocation inward 517 

163. Subastragaloid dislocation outward 518 



PRACTICAL TREATISE ON DISLOCATIONS. 



PART I. 

TRAUMATIC DISLOCATIONS. 



CHAPTEE I 



GENERALITIES. 



A dislocation is a permanent, abnormal, total or partial displacement 
from each other of the articular portions of the bones entering into the 
formation of a joint. 

Some authors have sought to restrict the application of the term 
dislocation to such injuries of the diarthroses or movable articulations, 
and to use for those of the fixed or much less movable joints the term 
diastasis. This proposed discrimination has not become generalized, and 
as it corresponds to no actual need, removes no uncertainty of meaning, 
and is simply an academical refinement of expression, there seems to be 
no pressing reason to adopt it. A positive objection to it, moreover, 
exists in the fact that the term diastasis is already employed to indicate 
a direct separation of articular surfaces, without lateral gliding of one 
upon the other, as when the pubic bones separate at the symphysis, or 
the tibia and fibula are torn apart, or in many injuries of the spinal 
column. 

If the displacement is only momentary, the parts immediately returning 
to their normal relations, the injury is classed as a sprain. 

When a coexisting wound of the soft parts establishes communication 
between the outer air and the cavity of the joint, the dislocation is said 
to be compound ; and when there exist associated lesions of the joint or 
neighboring tissues so extensive or peculiar as to present special indica- 
tions or create special difficulties in treatment, such as fracture or lacera- 
tion of vessels, nerves, or integuments, it is said to be complicated ; under 
other circumstances it is described as simple. 

When the articular surfaces are so far displaced that they no longer 
touch each other, or that they touch only by their edges, the dislocation 

2 



18 GENERALITIES. 

is said to be complete; if the displacement is less, it is called an incomplete 
dislocation or subluxation. Incomplete dislocations are frequent in the 
ginglymoid and arthrodial joints, and the controversy as to their frequency 
or infrequency in the enarthroses has arisen not from any doubt as to the 
nature of the new relations of the articular surfaces to each other or of 
the extent of the displacement, but solely from differences in definition, 
some authors maintaining that only those dislocations should be deemed 
complete in which the head of the bone has entirely left its bony socket, 
and all those incomplete in which any portion of the head remains within 
the area bounded by the rim of the socket, whether portions of the 
articular surfaces are in contact with each other or not. Under that 
definition many dislocations of the shoulder and of the hip would probably 
have to be classed as incomplete, if the exact relations of the bones could 
be determined ; and as such accuracy of diagnosis would rarely be at- 
tainable, and the doubtful cases would not differ clinically from those in 
which the displacement is greater, the adoption of such a classification 
would serve only to embarrass and obscure. It seems to me much simpler 
and more practical, even if somewhat arbitrary, to call all traumatic dis- 
locations of the hip and shoulder complete in which the centre of the head 
of the bone has passed beyond the rim of the socket. The incomplete 
dislocations would then be exceptional, practically only those in which a 
portion of the rim of the socket is broken off and pushed aside by the 
displaced head, as in a case mentioned by Robert 1 in an animated dis- 
cussion of this subject before the Societe de Chirurgie. 

In the great majority of cases the dislocation is of a single joint only, 
but occasionally two or more joints may be simultaneously dislocated, and 
the injury is then said, according to circumstances, to be bilateral, double, 
or multiple. When a symmetrical bone, having joints on both sides of 
the median line of the body, as the lower jaw or a vertebra, suffers dislo- 
cation of these joints, the injury is called bilateral or double. When both 
ends of a bone are dislocated, as has been observed in the clavicle, ulna, 
and fibula, the dislocation is said to be double or total. The same term 
is also applied to symmetrical dislocations on opposite sides of the body, 
as of both shoulders or both hips. The former has been caused by 
muscular contraction during an epileptic fit 2 and by external violence ; 
of the latter, two cases having a singular resemblance to each other have 
been reported, one by Boisnot, 3 the other by Schinzinger. 4 In the former 
a bale of wool fell upon a powerful man, forty years old, striking him 
upon the left side of the head and neck and bending him to the right, 
and caused a dorsal dislocation of the hip on the left side and a supra- 
pubic one on the right. In Schinzinger's case the patient, while bending 
forward, was struck upon the right side by a falling mass of earth and 
sustained an ischiatic dislocation on the right side and a suprapubic one 
on the left. Schinzinger thought it probable that the latter was caused 
by the efforts of the bystanders to drag out the man. For other cases 
see Chapters XVIII. and XXVII. 

1 Robert: Bull, de la Societe de Chirurffie, January 19, 1853, p. 389. 

2 Kronlein: Deutsche Chinir^ie, Lief. 26, p. 25. 

3 Boisnot: Amer. Journal Med. Sciences, October, 1867, p. 396. 

4 Schinzinger: Wiener med. Presse, 1880, quoted by Kronlein. 



GENERALITIES. 19 

Multiple dislocations are those in which two or more bones are simul- 
taneously dislocated, as two fingers, a shoulder and a hip. Some authors 
include under this term dislocation of two or more joints of a single bone, 
as when one of the small bones of the foot or wrist is forced completely 
out of its place. 

A method of nomenclature accurately descriptive of the different 
varieties of dislocation has not been established. As a general rule, 
subject, however, to some exceptions, the bone which is more distant 
from the trunk or median line of the body, the one that is generally 
moved upon the other, is said to be dislocated ; thus a dislocation at the 
hip, at the shoulder, is called a dislocation of the femur, of the humerus. 
Or the joint alone is named, as a dislocation of the elbow, of the hip, of 
the shoulder. As an example of the exceptions may be mentioned dis- 
location of the outer end of the clavicle, a term universally preferred to 
dislocation of the acromion. 

The same lack of uniformity appears in the names given to the various 
dislocations that may occur at the individual joints, and the practice has 
grown up of using in each case such a name as may most readily and 
accurately indicate either the general character of the displacement or 
some important special feature connected with it. When the name of 
the joint is used, and a term indicating direction is added, as dislocation 
of the elbow backward, forward, to the inner or to the outer side, the 
latter denotes the direction in which the distal member of the joint has 
been displaced. Whenever the use of the name of the joint would give 
rise to ambiguity, it is common to prefer the name of one of the bones 
constituting it, as a dislocation of the radius and ulna backward, instead 
of dislocation of the elbow backward. Strictly speaking, it is true that 
this might be mistaken for a dislocation at the wrist, and that, therefore, 
it would be well to add " at the elbow," but custom has so well established 
the meaning of the different terms now in use that in practice such a 
mistake would hardly be made. Other dislocations, again, have received 
names denoting the relations of the dislocated bone to certain muscles or 
bones, as subcoracoid or subpectoral dislocation of the humerus, and 
dislocation of the (head of the) femur upon the dorsum of the ilium or 
into the sciatic notch. 

The primitive or primary displacement is the one immediately effected 
by the causative violence which produces the dislocation ; if the dislocated 
bone afterward shifts to another position, the displacement is said to be 
consecutive or secondary. This shifting of the position of the dislocated 
end sometimes has very important consequences as regards treatment, 
because the end of the bone may thereby be removed from its position 
opposite the rent in the capsule through which it escaped from the cavitv 
of the joint, and, unless this rent is very large, it may need to be brought 
back to that position before it can be replaced in the joint. 

The earlier surgeons attributed this change of position to the action of 
the attached muscles, and although this opinion has been combated by 
high authorities, and although other causes undoubtedly take part in 
effecting the change, yet muscular action must, I think, be admitted to 
be one of the agents. Among the other causes are the action of gravity 
upon the limb, a new traumatism or a continuation of the orimary one, 



20 GENERALITIES. 

and movements communicated accidentally by the patient or bystanders, 
or intentionally by the surgeon in the effort to reduce the dislocation. 
Thus, in illustration of the last, it is not very rare to see an iliac trans- 
formed into an ischiatic or a thyroid dislocation of the hip in the effort 
to reduce by flexion, abduction, and rotation. 

In the great majority of cases a dislocation is produced suddenly by 
external violence or by extreme muscular action, or by the two acting 
together upon a healthy joint, and when thus produced it is called trau- 
matic. In other cases the joint has been diseased for some time previous 
to the occurrence of the dislocation, and this latter is effected by the 
gradual action of the muscles or even by gravity ; these are known as 
spontaneous, and present many varieties. (See Chapter X.) A third 
class, congenital dislocations, is composed of those in which the dis- 
location occurs during intrauterine life, presumably as the result of a 
malformation or defective development. Dislocations produced during 
delivery are traumatic. The second &nd third classes will be separately 
considered. (See Chapters IX. and X.) 

Statistics. — Compared with other surgical injuries, dislocations are 
infrequent. The statistics compiled by Gurlt 1 from the annual reports 
of the London Hospital for the years 1842 to 1877, give 51,938 fractures, 
5212 dislocations, 98,373 wounds, 23,180 contusions, 39,947 sprains, 
20,396 scalds and burns, 3715 dog-bites, and 975 suicidal attempts. The 
proportion of dislocations to fractures in this table is 1 to 10. Most of 
the statistics that have been published, especially the earlier ones, are 
defective in that they are based upon hospital, to the exclusion of dis- 
pensary, records, and therefore do not contain the due proportion of the 
less important varieties, or because of errors of diagnosis, notably in 
regard to dislocation of the wrist and ankle. It is only within the last 
forty years that the common injury now known as fracture of the lower 
end of the radius has been recognized as a fracture ; it was formerly 
deemed a dislocation. And in like manner Pott's fracture at the ankle 
is often found recorded as a dislocation. Kronlein's 2 statistics have the 
merit of being based upon the records for six and a half years (1874- 
1880) of a single hospital and polyclinic, and yet containing a number 
larger than that of any other except Malgaigne's, and large enough in 
itself to make it probable that the percentages do not vary widely from 
those that a larger number collected at the same place would give. They 
are as follows : 

1 Gurlt: Archiv fur klin. Chirurgie, 1880, p. 467. 2 Loc. cit., p. 5. 



GENERALITIES 



21 



Table I. — Table of 400 Recent Tbattmatic Dislocations (Kronlein). 





Kind. 


Sex. 








Age 








Totals. 




Joints. 


M. 


F. 


2 


° |° 
3 P 


o 

T 


3 




O tr- 
io .S 




X) 

t- 


Percentages of 
Frequency. 


Hip . . . J 


Iliac, 
Obturator, 


4 
2 
1 


1 


2 
2 


... 




l 




1 

"1 

1 

2 
35 

1 
3 

"3 
1 


i 
1 

19 

1 


... 
2 

1 

;;; 


3 • 

3 ■ 

2 
3 

203 ] 

94 1 109 
15 | 

1 

27 

8 

6 

11 

4 e} •« 

1 


2 1 

1.7 

0.5 

0.7 j 

51.7 

27.2 

0.2 
6.7 
2 
1 5 

2.7 

2.5 
0.2 




Knee . . . < 

Foot .... 
Metatarsophalangeal 

Shoulder . . .-I 

I 

Elbow . . J 

Wrist 

Metacarpo-phalangeal 

Interphalangeal 


Lateral , 
Patella ) 
outward, j 
Backward, 


4 

2 

1 
3 


1 
1 

23 

17 
6 

"i 
1 

2 

*2 
6 

64 


22 
9 

V 6 
1 

1 

"i 

44 


1 
2 

1 

2 

44 
5 

8 

3 

1 
1 
1 


1 
1 

53 
2 

14 

1 
1 
4 
5 
2 

1 
3 


l 
l 

14 
1 

5 

8 
1 

2 

"i 


48 

4 

1 

1 

"4 
2 


Lower 

■ extremity, 
20 = 5 


Subcoracoid ) 
and axillary j 

Erecta, 

Infraspinous, 

Of forearm, \ 
backward, J 

Of radius, 

Dorsal of ulna, 


180 

3 

1 

77 

9 
1 

23 

7 
4 


Upper 

- extremity, 

369 = 92.2 




"i '.'.'. 












11 
2 

"i 

336 




Lower jaw . . -j 


Unilateral, 
Bilateral, 


Trunk, 
s 11 = 2.8 






- 
69 


88 


65 


60 


48 


23' 3 






400 






4 


10 








4( 


10 











In addition, I quote those made up by Prahl 1 from the records of the 
Breslau Hospital and Polyclinic for the years 1830 to 1880, although 
they are probably affected by the errors of diagnosis above mentioned. 
Compared with Knonlein's, they show some important differences in the 
percentages, which may, perhaps, be due to an insufficient number of 
cases, or to differences in the habits and occupations of the population 
from which the cases were drawn. 



Table II.- 


-Table 


of 420 Traumatic Dislocations (Prahl). 






Age. 


























Percentages of 


JOINTS. 







01 


CO 




T 



10 



to 





00 






Totals. 


Frequency. 








5 


<M 


CO 


<* 


10 





S 


00 






Hip .... 




12 


8 


11 


5 


3 


2 








41 


9.76 ' 




Knee 












1 


1 


1 






1 








i\ • 


2.14 


Lower 


Patella 












1 


2 


2 














}■ extremity, 


Foot 












1 


4 


3 


1 


i 


2 


1 






13 


3.09 


65 = 15.48 


Toes . 














1 




1 












. 2 


0.47 




Shoulder . 












<5 


6 


27 


50 


36 


40 


24 


3 


2 


194 


46.19 ^ 




Elbow 












17 


26 


12 


7 


3 


3 


1 






69 


16.42 




Wrist 












1 


2 


3 


5 




1 


1 






13 


3.09 


Upper 


Thumb 2 












3 


4 


4 


2 


5 


3 


1 






21 


5 


y extremity, 


Fingers 












1 


1 


1 


9 


1 


1 


1 


i 




17 


4.04 


327=77.85 


Sterno-cla^ 


•icular 








1 


2 


1 


4 


1 




1 






10 


2.38 




Acroinio-clavicular 














2 


1 










3 


0.73 




Lower jaw 










3 


5 


6 


7 


2 


2 






25 


5.95 


Trunk, 
' 28 = 6.66 


Cervical vertebra 








44 


1 
61 


70 


1 


1 










3 


0.73 






93 


59 


55 


32 


4 


-- 


420 






















420 













1 Inane:. Dis. Breslau, 1880. Abstract in Centralblatt fur Chir'urgie, 1881, p, 57. 

2 As divided according to age, the numbers of the cases of the thumb and fingers 
amount to 22 and 16, respectively, instead of 21 and 17 as given in the main table. 



22 



GENERALITIES 



The total number of cases on the records was 453, of which 420 were 
traumatic, 100 females, 290 males, and 23 were congenital; of the latter, 
18 were of the hip, 15 females, 3 males, 2 each of the elbow and patella, 
and 1 of the knee. During the same period 2958 fractures were treated, 
a proportion of 7' to 1, reckoning the traumatic dislocations alone. 

The following, table has been made by combining Kronlein's statistics 
with a compilation made by Prahl of his own and others to show the 
direction in which the inclusion of dispensary or polyclinic statistics 
affects the percentages. 

Table III. 



Joints. 


Combined Hospital and 
Polyclinic. 


Hospital. 




Cases. 


Percentages. 


Cases. 


Percentages. 


Lower jaw . 

Vertebras . . . . , . 


1} « 


3.4 } Trunk, 
0.5 j 4 


*?} 19 


1.2 | Trunk, 
0.7 j 1.9 


Sterno-clavicular . 
Acromio- clavicular 

Shoulder 

Elbow 

Wrist, thumb, and fingers 


451 

14 | 
648 V1173 
315 j 
151 J 


3.11 

0.9 | Upper 
45.2 ]■ extremity, 
22 81.2 
10.5 j 


681 
... | 
581 y 794 
97 | 
48 J 


7 1 

1 Upper 
60.2 y extremity, 
10 i 82.3 

5 j 


Hip 

Knee 

Patella . . . . 

Ankle 

Tarsus and toes .... 


1271 
18 | 

13 y 202 
35 | 
9J 


8.8 1 

1.2 | Lower 
0.9 y extremity, 
2.4 | 14.1 
0.6 J 


851 
16 | 

5 y 151 

33 | 
12J 


8.8 1 

1.6 1 Lower 
0.5 y extremity, 
3.4 j 15.6 
1.2 J 




1432 




964 





The following table summarizes the others with Malgaigne's statistics 
of the Hotel Dieu. 

Table IV. 



Malgaigne, hospital 
Kronlein, hospital and polyclinic . 
Prahl, hospital and polyclinic 
Table III., hospital and polyclinic 
Table III., hospital. 



Upper extremity. 



85.7 per cent. 

92.2 " 

77.8 

81.2 

82.3 



Lower extremity. 



12.6 per cent. 
5 
16 
14.1 
15.6 



Trunk. 



1.6 per cent. 

2.8 

6 

4 

1.9 



These tables show the great relative frequency of dislocations of the 
upper extremity as compared with those of the lower. Each set of statis- 
tics shows that dislocation of the shoulder is far more common than that 
of any other joint, the percentages varying from 45.2 to 60.7 ; that next 
in frequency come dislocations of the elbow, with percentages varying 
from 10 to 27.2. These two dislocations may be estimated as together 
comprising from two-thirds to three-fourths of all cases; of the remaining 
one-third or one-fourth, dislocations of the fingers and hip form the 
majority. 

The side upon which the dislocation took place is so seldom mentioned 
in the records from which the statistics have been compiled that no posi- 



GENERALITIES, 



23 



tive opinion can be formed as to the relative frequency with which the 
two sides are affected. Kronlein found in 100 consecutive cases observed 
by himself the right side was affected 46 times, the left 54. 

As between males and females, Malgaigne and Gurlt found the injury 
three times as frequent in the former as in the latter ; Kronlein found it 
five times as great. Dislocations of the lower jaw are an exception, being 
four times (Kronlein) as frequent in women as in men. 

Age. — No age is exempt ; dislocations have occurred as early as the 
moment of birth and as late as the age of ninety years. The relative 
liability to the injury at different ages is not shown by simply comparing 
the number of cases observed at those ages, but by also comparing these 
numbers with the number of people at those ages living in the community 
where the observation is made. This comparison has been made by 
Kronlein for Berlin, with the following results : 

Table V. — Frequency of Dislocations at Different Ages. 



Absolute frequency .... 

Relative number of people living 

Relative frequency as computed for equal num- 
bers of people 



1-10 


11-20 


21-30 


31-40 


41-50 


51-60 


61-70 


u 


69 


88 


65 


60 


48 


23 


1872 


1620 


2529 


1679 


940 


599 


282 


10 


18 


15 


16 


27 


35 


35 



3 

117 

10 + 



From this it appears that a smaller proportion of individuals between 
the ages of 1 and 10, and 71 and 80 years receive dislocations than in 
any other decade of life ; and the highest proportions are found between 
the ages 51 and 60 and 61 and 70. It is further to be noticed that dis- 
location of the shoulder is very rare, and that of the elbow very common, 
before the age of 21 years. Kronlein's table (Table I.) shows that of 
207 cases of the former, in only 2 were the patients less than 21 years 
old, and that of 109 cases of the latter 80 were no older, the age in 31 
being between 1 and 10 years, and in 49 between 11 and 20 years. 
Prahl's table (Table II.) corroborates this. Compared with fractures, it 
appears that the liability to dislocation is least during those periods of 
life in which the liability to fracture is greatest — that is, in infancy and 
youth and in old age; the latter part of this statement may need some 
modification, for while dislocations are rare after the age of 70, they 
are relatively frequent in the preceding decade. The liability to each 
increases from adolescence through middle life. 



CHAPTEE II. 



ETIOLOGY AND MECHANISM. 



The causes of dislocation may be grouped in two classes : a. Predis- 
posing ; b. Immediate or determining. 

a. Predisposing Causes. — These are found in certain normal differ- 
ences of form and function characterizing certain joints, and in accidental 
or pathological conditions that sometimes arise. 

The joint which is most frequently dislocated is the shoulder-joint, and 
it differs normally from others in the wide range and variety of motion 
made possible by its form, the laxity of its capsule, and the absence of any 
firm ligament to hold the bones closely together. A wide range of motion 
in one direction is not necessarily a circumstance favoring dislocation ; 
on the contrary, it may protect against it by making it difficult to bring 
into action the fulcrum which is furnished by the edge of the bone when 
it arrests the motion. In a young healthy person the elbow or knee cannot 
be dislocated by flexion, because the motion is finally arrested by broad 
contact of the soft parts, not by the edge of the joint; while, on the other 
hand, in each case extension is limited by the structures of the joint itself, 
and hyper-extension at once causes dislocation by rupturing those struc- 
tures. A long range of motion in one plane does not make the joint 
insecure, so long as the two bony surfaces rest squarely against each 
other, as they do in the hinge-joints ; but when the change of position 
makes this contact oblique, as in abduction of the arm, a displacing force 
exerted in the direction of the long axis of the humerus is resisted only 
by the capsule. Under certain conditions, therefore, it may be said that 
freedom of motion in a joint diminishes, and limitation of motion increases, 
the liability to dislocation. A force which, exerted in the plane of normal 
motion of a hinge-joint, would be taken up by the muscles without damage 
to the joint, would, if exerted in another (lateral) plane, rupture the liga- 
ments and dislocate the joint. If the edges of bone or the processes about 
a joint are exceptionally prominent they may, by virtue of this condition, 
become predisposing causes of dislocation by arresting motion. 

Dropsy of such a joint as the shoulder favors its dislocation by remov- 
ing the obstacle which the necessity of creating a vacuum between the 
articular surfaces would otherwise interpose, and by giving to the head 
of the humerus a different range and character of motion and the possi- 
bility of finding new bearings (see Chapter X., Dislocations by Dis- 
tention). 

The destruction of the ligaments by violence or disease, and fracture 
or disease of the bony constituents of the joint, favor dislocation, and the 
fracture of an associated or parallel bone may have the same effect, as 
fracture of the ulna favors dislocation of the head of the radius. 



ETIOLOGY AND MECHANISM. 25 

b. Immediate or Determining Causes. — A bone may be dislocated by 
(1) external violence applied (a) directly to it at or near its end, or (b) 
indirectly and at a distance from its end ; (2) by muscular action. 

1. External violence. Dislocations by direct violence are rare, espe- 
cially if the class is restricted to those cases in which the violence falls 
upon only one of the bones forming the joint and forces it directly away 
from the other. Thus, the head of the humerus has been driven back- 
ward (subspinous dislocation) by a blow of the fist (Busch) or by a fall 
in which the front of the shoulder struck against the corner of a table 
(Kronlein), or inward by a fall upon the outer side of the shoulder, or 
even downward into the axilla by a force received upon and first breaking 
the acromion (Kronlein). 

Intermediate between these cases and those in which the force is trans- 
mitted through the entire length of the shaft of the bone or of the limb, are 
those in which the force acts at right angles to the axis of the limb, and 
is received either at the joint or at a variable distance from it. Thus, 
the foot and body being fixed, the knee is forced to one side, producing 
rupture of a lateral ligament, lateral flexion, and dislocation ; or, the 
femur being fixed, the leg is carried forcibly to one side and the same 
injury is produced. The mechanism and the consequences are identical 
in the two cases, but the former would be classed by some authors as a 
dislocation by direct violence, and the latter as one by indirect violence. 

In dislocations by indirect violence the mechanism may vary greatly. 
The force in some cases is exerted directly along the long axis of the 
bone while the limb is in a position in which the articular surfaces do not 
rest squarely upon each other, and the head of the bone is driven out of 
its socket, as in some dislocations of the shoulder by a fall upon the out- 
stretched (abducted) arm, or by muscular action, or in dislocation of the 
outer end of the clavicle by a fall upon the shoulder. The mechanism is 
similar to that of the first form of dislocation by direct violence mentioned 
above. Or a much slighter force, favored by conditions of leverage estab- 
lished at the joint, tears the capsule or a ligament and produces a dislo- 
cation. This is the most common mechanism. The conditions of leverage 
are found at all points where normal movements are arrested or no move- 
ment permitted. The head or neck of a moving bone is arrested by the 
edge of the corresponding articular cavity, or by a projecting point of 
bone, or by a tense ligament or portion of capsule ; this at once becomes 
a new centre of motion, a fulcrum, and, the force continuing: to act at the 
end of the bone or limb (the long arm of the lever), the head of the bone 
(or short end of the lever) is forced away abnormally -with rupture of the 
opposing ligament or capsule. A position may be given to a limb by 
rotation or by abduction or adduction, such that the capsule of the joint is 
made tense and a dislocation by flexion or extension of the limb becomes 
imminent long before the normal limits of the latter motion are reached. 
Thus, when the thigh is slightly flexed and adducted, inward rotation of 
the limb will usually produce a dislocation of the hip with comparative 
facility. 

When the force is exerted in a direction in which normally no motion 
is permitted, as laterally at the elbow, ankle, or knee, it meets at once 
with greater resistance than that habitually found at the extremes of 



26 ETIOLOGY AND MECHANISM. 

normal ranges of motion, and if it is great enough to overcome this resist- 
ance it is more likely to cause in addition other and perhaps extensive 
injuries of the soft parts or of the bones. The injury produced in this 
manner at the ankle is, indeed, classed as a fracture, although the partial 
or complete displacement of the astragalus, from its relations with the 
tibia, gives rise to the most prominent features of the injury, and may, if 
uncorrected, cause great permanent disability. 

Violence, then, acting in a given manner, may cause a fracture, a dis- 
location, or a sprain according to its force, the strength of the resistance 
offered by the ligaments and the bones to which they are attached, and 
the prolongation of its action. 

2. Muscular action. Contraction of the corresponding muscles can 
cause the dislocation of a sound joint in either of two ways : it can, by 
rapidly moving the limb, communicate to it a momentum which acts in 
the same manner as external violence and produces a dislocation when 
the normal limits of the range of motion are reached and conditions of 
leverage are established. A case, probably of this kind, was observed by 
Sedillot r 1 a woman, forty-six years old, who dislocated her shoulder by 
raising her arm to strike. a blow. Or, secondly, the muscular contraction 
acts like external violence received at or near the end of the bone, or 
transmitted along its longitudinal axis, and draws the bone out of its 
socket. For this it is essential that one or two muscles should contract 
violently, while the others that normally act upon the joint remain 
passive, or that the limb should be in such a position that the line of 
traction of the muscles makes an acute angle with the opposing articular 
surface. Instances of this kind are common at some joints ; dislocation 
of the lower jaw is commonly caused by muscular action, in yawning, 
laughing, vomiting, and others have been caused in like manner at the 
shoulder and hip, and, very exceptionally, at other joints. As illustrative 
examples may be mentioned the following : 

A man sought to draw in through a window a heavy bale of goods 
suspended from a crane, and as he pulled upon it with his arms raised he 
felt a painful snap in the shoulder, and was found to have dislocated the 
humerus into the axilla. Apparently this was effected by the direct 
traction of the pectoralis major and latissimus dorsi. 

A man, fifty-one years old, dislocated both shoulders (subcoracoid) by 
drawing himself up with his hands ; a painter dislocated his shoulder 
while painting a ceiling ; a woman, by trying to lift a heavy object from 
a shelf; a man, by trying to lift at arm's length a heavy book from the 
floor ; and a woman, by carrying a heavy load upon her head with both 
arms uplifted. 

Many cases have been reported in which dislocation has been caused 
by the convulsive contractions of individuals affected with epilepsy, 
tetanus, or uraemia, or poisoned with strychnine. In many of the cases 
reported as such the dislocation may have been caused by violence re- 
ceived in falling during the fit or by striking the limb against some 
object, but in a number of them the history positively establishes the 
absence of any other cause than the contraction of the muscles. 

1 Sedillot: Diet. Encyclopedique, art. Luxations, p. 23. 



ETIOLOGY AND MECHANISM. A i 

In these cases, as in fractures by muscular action, it is unnecessary to 
suppose, and unwarranted to claim, that the strength of the capsule or 
ligaments is less than usual, or that the structure of the joint varies from 
the normal in such a way as to facilitate the production of the dislocation. 
Such a supposition is based on the theory that a normal joint is so con- 
structed as successfully to oppose any force that can be exerted upon it 
by its own muscles. Nature's precautions are based upon what is prob- 
able only, as we are taught by daily experience in many things ; and it 
is no more remarkable that a healthy, normal joint should be dislocated 
by excessive muscular action than that a sound bone should be broken in 
the same way ; it is only necessary that the force should be exerted in 
the same direction and should be equal in amount to that of the external 
violence which can produce the same injury, and anatomy shows us that 
both these conditions may exist. Moreover, in the first class of cases the 
mechanism is identical with that of dislocations by external violence, the 
only point of difference being that in them the place of external violence is 
taken by the momentum developed in the limb by the action of the muscles. 

The power of voluntary dislocation of one or several joints has been 
occasionally observed. In a large proportion of the cases its appearance 
has followed the occurrence of a traumatic dislocation of the same joint, 
but in a few instances the history of the individual contained the record 
of no traumatism or diseased condition to which the peculiarity could be 
reefrred. In a case reported by Chassaignac 1 the subject was a saltim- 
banco, and seemed to have developed the power by forcing his joints in 
the practice of his art ; he could dislocate each hip backward and upward, 
and then change the displacement into an ischiatic dislocation. Another 
man, Charles H. Warren, who possessed the power in a remarkable degree, 
has been examined and reported upon by several surgeons, notably by 
Hamilton, 2 who has given a very full account. In a case reported to Sir 
Astley Cooper, 3 a man, fifty years old, could dislocate either hip back- 
ward u by turning the limb considerably inward and bending the knee 
slightly, when the head of the femur immediately, with a crack, slips out 
in the direction backward and a little upward, the neck resting upon the 
acetabulum, and by reversing the position of the limb the bone returns 
into its natural position." He had possessed the power for about twenty- 
six years ; the dislocation first occurred in consequence of simple change 
of position, and was reduced without surgical aid. 

Recurrent or Habitual Dislocations. — Individuals are occasionally 
observed in whom dislocation of some one joint, commonly the shoulder, 
but also the hip and jaw, frequently recurs under the influence of some 
slight cause, and who have acquired this liability as the result of an 
ordinary traumatic dislocation, or of paralysis of one or more of the 
muscles of the joint, or of fracture. The first class will be considered in 
Chapter III. ; of the others the following case, reported by Sir Astley 
Cooper, 4 will serve as an illustration: "A gentleman happened, as a 
junior officer on board his ship, to be placed under the orders of one of 
the mates when the captain was on shore, and for some trifling offence 

1 Chassaignac: Bull, de la Societe de Chirurgie, 1853, vol. iii. p. 391. 

2 Hamilton : Fractures and Dislocations, 7th ed., p. 807. 

3 Cooper: Dislocations and Fractures, Am. ed., 1844, p. 7. 
i Loc. cit., p. 9. 



28 ETIOLOGY AND MECHANISM. 

was punished in the following manner : his foot was placed upon a small 
projection on the deck, and his arm was lashed tightly toward the yard 
of the ship, and thus kept extended for an hour. When he returned to 
England, he had the power of readily throwing that arm from its socket 
merely by raising- it toward his head, but a very slight extension reduced 
it ; the muscles were also wasted, as in a case of paralysis." 

The explanation is to be found in the loss of support occasioned by the 
diminution or loss of the tonicity of the muscles, which, in such joints as 
the shoulder, take the place of short, firm ligaments and hold the articular 
surfaces in contact with each other, a loss which allows the bones to be 
separated by the action of gravity, or by an effusion into the joint, until 
the separation is arrested by the capsule. When thus separated, a slight 
force is sufficient to throw the head of the humerus past the edge of the 
glenoid cavity and produce a dislocation without rupture of the capsule. 

The cases of dislocation due to limited paralysis of peripheral origin 
must not be confounded with those sometimes accompanying' the arthro- 
pathies that complicate some paralyses of central origin and some cases of 
central nervous disease without paralysis. In the latter the articular 
portions of the bones are absorbed in the progress of the disease, and thus 
even a joint the bones of which are normally held close together by 
ligaments becomes a loose one by loss of bone substance. I have seen 
a case of this kind in which the left femur could be very easily dislocated 
upward and backward. The symptoms were very different from those 
characteristic of the common traumatic form, since the loss of the head 
of the femur permitted free motion of the limb when dislocated and 
allowed the foot to be notably everted. 

In another case, probably of the same kind, which I saw in the wards 
of La Charite in Paris,, the patient, a woman, forty-six years old, had 
been received into the medical wards for supposed disease of the spinal 
cord, and while in bed there was suddenly seized with sharp pain in the left 
hip. Prof. Gosselin, called in consultation by Bernutz, found the limb 
shortened and everted, pain on pressure in front of and behind the hip- 
joint, some swelling in Scarpa's space, and crepitation on moving the 
limb, and made the diagnosis of spontaneous fracture of the neck of the 
femur. Two days later the patient was free from pain and could move 
the limb freely and vigorously, the foot remaining constantly everted. A 
few w T eeks later, her temperature rose suddenly to 106J°, and she soon 
died. The autopsy showed that the head and neck of the femur, the 
upper and outer portion of the rim of the cotyloid cavity, and all the 
articular cartilage of the latter had disappeared, leaving an eburnated 
surface. The joint was full of pus, which communicated through a hole 
in the capsule with an abscess in the buttock, and there was pus in the 
knee-joint. Prof. Grosselin then said that the non-existence of a fracture 
was incontestable, but he was indisposed to accept Bernutz's theory that 
the affection was an arthropathy of nervous origin. 

Strictly speaking, cases like this, in which the articular end of the 
bone has been entirely absorbed, do not come within the definition of 
dislocation, but clinically it is proper and convenient so to designate 
them. (See Chapter X.) 

The unequal growth of parallel and associated bones, tibia and fibula, 
or radius and ulna, may cause dislocation at one or the other end. 



CHAPTEE III 



PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS; COMPLICATIONS; 
AND THE PROCESS OF REPAIR AFTER REDUCTION. 

As a traumatic dislocation consists in the forcible overcoming of the 
normal restraints upon the motion of the joint in one or more directions, 
restraints offered by the ligaments and capsules of the joint, it is almost 
invariably accompanied by rupture of a ligament or of the capsule. There 
is some reason to think that dislocation of the inferior maxilla may be 
an exception to this rule, but the lack of opportunities directly to examine 
such cases leaves the question in doubt. In a case examined by Nelaton 
and Malgaigne the ligaments and capsule were found intact, but the 
patient was old and the dislocation had taken place five different times, 
so that the examination cannot be held to prove even the possibility of 
a first dislocation without laceration of the soft parts. In enarthrodial 
joints, especially the shoulder, where the ligaments are loose and where 
the bones are held together by the tonicity of the muscles and the atmos- 
pheric pressure, such a change as dropsy of the joint may so annul the 
effect of the latter agent and overcome the former by filling the capsule 
with liquid that insinuates itself between the contiguous articular surfaces, 
that the head of the bone falls away from its socket and the joint becomes 
loose like that of a flail ; under such circumstances dislocation may occur 
without rupture or laceration. 

The capsule of an enarthrodial joint is torn upon the side toward which 
the distal bone is displaced ; in joints of other forms the ligaments may 
be broken on either or both sides, the extent and character of the injury 
varying with the character of the force. Thus, if a ginglymoid joint, 
like the elbow, is bent laterally toward the inner side until the external 
lateral ligament gives way, the ulna and radius may then be displaced 
backward without further laceration ; but if the force continues to act 
and displaces the bones laterally, the internal lateral ligament must also 
yield. The rent in the capsule may be limited in extent and simple in 
form, merely a longitudinal or transverse slit, or it may be irregular and 
may even involve the entire periphery. Instead of suffering a rent, the 
capsule may be torn away from the bone, sometimes bringing with it 
portions of the bone itself, or remaining continuous with the periosteum 
stripped up from the shaft. 

Under similar conditions the position of the rent in the capsule is very 
constant, for it is determined by the posture of the head and the direction 
of the force, and as the end of the bone may pass through the rent, and 
then be brought by a change in the posture of the limb to a point where 
an untorn portion of the capsule lies between it and the cavity of the 
joint and whence it can be replaced only by first bringing it back to the 



30 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

place where it escaped, it is sometimes of the greatest importance to 
ascertain the position occupied by the limb at the moment the dislocation 
occurred, and to replace it in this position as the first step in making the 
reduction. 

In addition to the laceration of the capsule and ligaments produced 
by the pressure of the bone, others may be caused by the tearing off of 
attached muscles that are put upon the stretch by the displacement. This 
is commonly accompanied by the avulsion of the tuberosities upon which 
the muscles are inserted ; the bone yields, and the laceration, starting 
from the broken surface, extends across and through the adjoining soft 
parts. This is an habitual accompaniment of dislocation inward and 
downward of the shoulder ; the supra-spinatus and infra-spinatus muscles, 
inserted respectively upon the upper and middle facets of the greater 
tuberosity of the humerus, are put upon the stretch and one or both are 
torn away from the bone. I possess a specimen of dislocation inward in 
which this avulsion of the tuberosity, with a slight rent extending into 
the capsule from it, is the only lesion. 

The soft parts overlying the capsule may be torn by extension of the 
rent in the capsule if they are closely adherent to the latter, or by the 
forcible passage through them of the displaced bone. The surrounding 
muscles on the side toward which the displacement takes place are con- 
tused or torn by the passage of the bone, and those upon the opposite 
side may be torn by being put upon the stretch. Blood is freely extra va- 
sated into the cellular tissue from the ruptured vessels. 

The cartilages of incrustation may be bruised and sometimes chipped 
in the passage of the surfaces across each other, and projecting portions 
of bone, apophyses, or the rim of an orbicular cavity may be broken off. 

The bone itself seldom passes to any great distance from its normal 
position; its progress is arrested by the ligaments and muscles that 
remain untorn and the resistance of the soft parts that it presses upon, 
and it comes to rest lying directly upon the adjoining bone or with some 
soft parts interposed. Its position, as taken in the primary displace- 
ment, may be changed by the renewal of external violence, by gravity, 
by a change in the position of the limb, or by the spasmodic contraction 
of attached muscles, but the secondary position ( u consecutive displace- 
ment") is habitually determined by the resistance of untorn ligaments 
which constitute the fulcrum or pivot about which the bone turns. This 
fact, the resistance of untorn ligaments, should always be kept promi- 
nently in mind, for it not only constitutes one of the great obstacles to 
reduction, but it also determines the direction and extent of the manoeuvres 
by which reduction may be accomplished. 

Complications. — Other injuries, and severer or more extensive forms 
of those already mentioned, may coexist with a dislocation as complica- 
tions. They include fracture of the bone, partial or complete rupture of 
large bloodvessels or nerves, and extensive laceration of the soft parts. 
In order that the associated injury should constitute a "complication" 
of the dislocation, it is agreed that it should be the direct or consecutive 
result of the original violence upon adjoining tissues, and should create 
special indications for, or difficulties in, treatment. A fracture of the leg 
caused by the same fall that dislocates the shoulder is not, in this sense, 



PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 31 

a "complication" of the dislocation; but a fracture of the ulna accom- 
panying dislocation of the radius, or a fracture of the surgical neck of the 
humerus accompanying dislocation of the shoulder is a complication, for 
the two injuries are mutually interdependent in their origin and in their 
treatment. 

Bones. — All fractures that coexist with dislocation of even the same 
bone are not necessarily to be deemed complications, since many such 
habitually accompany certain dislocations, may even not be recognizable 
clinically, and neither receive nor require special treatment. Such are 
fractures of apophyses or tubercles to which muscles are attached, and 
fractures of a portion of the articular end of the bone or of the rim of an 
orbicular cavity. In others the dislocation is rather to be deemed the 
complication of the fracture, since it presents the less prominent symp- 
toms and it may be entirely impracticable to meet the special indications 
for its treatment ; such are some fractures through the anatomical neck 
of the humerus or femur with dislocation of the head. On the other 
hand, there is one injury habitually classed with fractures, Pott's frac- 
ture at the ankle, the treatment of which would, I think, yield much 
better results if it were looked upon as a dislocation and if the treatment 
were more distinctly directed to the reduction of the displacement and 
the prevention of its recurrence. It is far more common than it should 
be to meet with cases of this kind in which repair has taken place with 
the foot permanently displaced to the outer side, a result which is not 
only a deformity, but often also involves great disability. 

A very rare manner in which this combination of fracture and disloca- 
tion is produced is that in which the fracture is first effected by direct 
violence, and thereby a way is opened for the production of the disloca- 
tion by the continued action of the original violence. Kronlein (loc. cit., 
p. 30) reports two examples that came under his own observation : in 
one the acromion was broken by a blow received directly from above, and 
then the humerus was dislocated inward and downward ; in the other, by 
a fall upon the fully flexed elbow a compound transverse fracture of the 
olecranon was caused, and then a complete dislocation of both bones of 
the forearm forward. A more common form of similar character is that 
in which, by the fracture of one of two parallel bones, the dislocation of 
the other is facilitated, as in a case now under my care in which a lad 
seven years old by a fall upon the outstretched hand broke the ulna just 
below its centre and dislocated the head of the radius forward and upward. 

Much more common are those in which the force is exerted through 
the distal segment of the limb and the head of the bone upon the margin 
of the opposing articular surface, breaking off the latter ; the dislocated 
bone leaves the joint through the gap thus created, driving the fragment 
before it, or also tears the capsule and escapes in the usual manner. The 
commonest examples of this kind are found in fractures of portions of 
the rim of the glenoid and cotyloid cavities. Others, that are closely 
analogous, are fractures of the coronoid process of the ulna in dislocation 
backward of both bones ; and I have once seen the inner third of the 
head of the radius broken off in the same dislocation. 

A case of similar partial fracture of the head of the femur accompany- 
ing its dislocation backward is reported by Mr. Birkett, in the Medico- 



32 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

Chirurgical Transactions, 1869, vol. 52, p. 133. The patient, a woman, 
thirty-five years old, received the injury, together with others that caused 
her death on the fifth day afterward, by a fall from a height of twenty 
feet ; the head of the femur was divided by a vertical line of fracture, and 
the inner fragment, which included the attachment of the ligamentum 
teres, remained in the cotyloid cavity, while the remainder, with the 
neck, was dislocated backward between the pyriformis and the obturator 
internus. Another very similar case was reported by Moxon in The 
Medical Times and Gf-azette, 1872, i. p. 96. It is quoted in Chapter 
XXV. — compound dislocations of the femur. 

In connection with this, although the mechanism appears to have been 
different, a very remarkable case recently reported by Riedel at the Four- 
teenth Congress of the German Surgical Society 1 needs mention. A lad 
fifteen years old was run over by a heavy car, probably while lying on 
his side. The appearance of the limb suggested an iliac dislocation of 
the hip, but was not characteristic, and, on manipulation, indistinct crepi- 
tation was felt. After removal of the trochanter the head and neck 
of the femur were found to be fractured longitudinally into two pieces. 
Both fragments lay outside the acetabulum, the upper and posterior por- 
tion of which was crushed. It seemed as if the head must have received 
a second blow at the moment when it rested on the edge of the acetabu- 
lum, and was thereby split in two. 

A very rare complicating fracture is that of the central part of the 
acetabulum when the head of the femur is driven through it into the 
cavity of the pelvis by great violence. Sir Astley Cooper 2 briefly reports 
one such case " having the appearance of a dislocation backward ; the 
patient lived four days. On examination, the fracture was found passing 
through the acetabulum, dividing the bone into three parts ; and the head 
of the thigh bone was deeply sunk into the cavity of the pelvis." 

Still more common, but seldom deserving to be classed as complica- 
tions, are those fractures by avulsion, already referred to, in which, 
ligaments or muscles being put upon the stretch, the bony prominences 
to which they are attached are torn off. Some of them may be looked 
upon as habitual, or at least frequent, accompaniments of certain disloca- 
tions, for example, fracture of the greater tuberosity of the humerus 
in dislocation of the shoulder inward or downward, and fracture of the 
internal malleolus by displacement outward of the foot. This variety of 
complicating fracture, and also that in which a portion of the margin of 
the orbicular cavity is broken off, may become of special importance by 
facilitating recurrence of the dislocation. 

The form in which the complication most seriously affects the treatment 
and prognosis is that in which the bone is broken completely across near 
the dislocated end. The commonest examples are found at the shoulder, 
where the line of fracture follows either the anatomical or the surgical 
neck, and the special difficulty in treatment arises from the smallness of 
the upper fragment, whereby it is made difficult or impossible so to act 
upon it as to return it to its normal position in the joint. In 68. cases of 

1 Riedel : Beilage zum Centralblatt fur Chirurgie, 1885, p. 92. 

2 Cooper: Dislocations and Fractures, Am. ed., p. 101. 



PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 33 

this kind collected by Thainhayn 1 14 were of the anatomical neck of the 
humerus, and of these in only 2 was the dislocation reduced ; while of 
the 46 cases in which the fracture occupied the surgical neck, 20 were 
reduced. A number of illustrative examples have been given elsewhere 
(Fractures, p. 372). The mechanism of the combined lesions is some- 
times obscure, as regards its details, and varies in the different cases, the 
dislocation sometimes preceding and sometimes following the fracture, and 
perhaps sometimes occurring simultaneously. When it follows the frac- 
ture it is due to a continuation of the external violence acting directly or 
indirectly upon the upper (dislocated) fragment, or, if the fragment is very 
small and loosely attached, as after fracture through the anatomical neck 
of the humerus, to any slight force that may rotate or displace it in the 
loose capsule. In a specimen figured by Kronlein the head of the humerus, 
after fracture of the anatomical neck, has been completely reversed and 
lies wedged between the tuberosities. When the fracture follows the dis- 
location its production is doubtless aided, in most cases, by the comparative 
immobility of the head of the bone in its new position due to the creation 
of new bearings or fulcrums which fix the position of the limb. This is 
clearly illustrated by those cases in which the fracture has been caused 
by the surgeon in an attempt to reduce the dislocation. 

The importance of this form of the complication lies not so much in the 
coexistence of two serious injuries, as in the difficulty of reducing the 
dislocation and in the necessity, if reduction fails, of seeking to establish 
a pseudarthrosis that will leave the limb measurably useful. 

Bloodvessels. — Injury of a large bloodvessel adjoining a dislocated joint 
(the dislocation not being compound) is a comparatively rare accident, 
and one that depends either upon the close relations of the vessels and 
the bones, as at the shoulder and knee, or upon violence so great as to 
displace the bone to a greater distance than usual, or in an unwonted 
direction. 

In most of the recorded cases the dislocation has been of the shoulder, 
inward and forward, and the lesion has consisted either in the rupture of 
a large arterial branch, the anterior circumflex or the subscapular, at or 
near its origin, or in such stretching of the axillary artery that its inner 
and middle coats have been torn across, the outer one remaining un- 
divided. The injury may result in the immediate formation of a traumatic 
aneurism or in the gradual formation of an encysted one, or in gangrene 
of the distal portion of the limb. In some of the recorded cases it is not 
possible to determine whether the injury to the vessel was the immediate 
result of the dislocation or of the efforts to reduce it. (See Chapter VIII.) 

The symptoms vary greatly, but, except at the shoulder, are not likely 
to leave any doubt concerning the nature and details of the injury. 
Injury to the inner and middle coats alone may in some cases be recog- 
nized by the immediate cessation of the brachial and radial pulse, in 
others only by the subsequent gradual formation of an aneurism. In 
other cases the prompt appearance and rapid growth of a fluctuating 
swelling in the axilla, perhaps accompanied by extensive ecchymosis and 
alarming symptoms of collapse or shock, sufficiently prove the fact of an 

1 Thamhayn : Schmidt's Jahrbuch, vol. 140, 1868 
3 



34 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

internal hemorrhage ; but the source of the bleeding, whether from an 
arterial branch, the main artery, or the vein, may remain in doubt, for 
the radial pulse may persist even when the hemorrhage comes directly 
from the axillary artery. The subject will be more fully discussed in 
Chapter VIII. " 

In a case observed by Korte, 1 this complication accompanied a disloca- 
tion of the shoulder caused by a blow received upon its upper surface 
while the arm was abducted ; the dislocation was spontaneously reduced 
before the arrival of the surgeon, and probably the displacement was only 
slight. An aneurism formed, and w T as opened under the impression that 
it was an enlarged lymphatic gland. The autopsy indicated that the 
lesion was avulsion of the anterior circumflex artery at its origin, and 
showed also that the inner and middle coats of the axillary artery were 
torn transversely at a higher point, but the calibre of the vessel was not 
thereby obstructed. 

A somewhat similar case was reported by Despres, 2 in which the 
patient's arm had been violently twisted in different directions. Although 
a dislocation had not been suspected, the autopsy (death having followed 
gangrene of the arm in the ninth week) showed a rent in the capsule on 
its inner and anterior side, and the joint was filled with blood-clots, so 
that it is probable a dislocation had occurred. The axillary artery was 
intact, but the common trunk of the circumflex arteries had been torn off 
at its origin. 

These two cases illustrate one variety of the complication at the 
shoulder and the mechanism by which it is produced. Of another, 
damage to the wall of the axillary artery by over-stretching, the following 
may serve as an example, although it is possible that the injury was pro- 
duced during reduction. Nelaton 3 refers to a case under the care of 
Berard, a subcoracoid dislocation of the humerus, in which the axillary 
artery was torn completely across through its inner and middle coats, and 
the outer coat was " elongated like a glass tube drawn out in a flame." 
The lesion was followed by gangrene of several fingers, and, finally, by 
the death of the patient. He speaks, also, in two places 4 of what appears 
to have been a single case of similar character under his own care ; the 
two inner coats of the axillary artery were torn to a very limited extent, 
and an aneurism formed, for which he tied the subclavian artery three 
months later, with a fatal result. 

The following cases illustrate other varieties : 

Mr. J. W. Turner 5 reported two cases of rupture of the popliteal artery 
complicating dislocation of the knee. In the first a man, twenty-four 
years old, fell from a height of thirty feet and sustained a compound dis- 
location of the knee, the condyles of the femur projecting through the 
integument of the ham. The limb w T as immediately amputated, and the 
two inner coats of the popliteal artery w r ere found to be ruptured, the 
outer coat remaining untorn. 

1 Korte: Archiv fur klini^che Chirur-ip, 1882, p. G86. 

2 Despres: Bulletin de la Soeiete de Chirurgie, 1878, p. 116. 

3 Nelaton : Pathologie Externe, 1st od., vol. ii. p. 368. 

4 Loc cit., pp. 302 and 3B8. 

5 Turner: Trans. Edinburgh Med. -Chi r. Soc, vol. iii. p. 308. 



PATHOLOGICAL ANATOMY IX RECENT DISLOCATIONS. 35 

In the second ease a middle-aged woman fell while carrying a heavy 
burden on her back. When she was brought to the hospital there was 
found a dislocation of the knee together with a wound in the ham through 
which, it was said, the condyles of the femur had projected. There was 
no bleeding ; the limb became greatly swollen, and the patient died on 
the tenth day. The artery and vein were found to have been torn 
completely across. 

Dr. M. Goldsmith 1 reported the case of a man, forty years old, who 
suffered a dislocation of the left femur, tk the head of the bone being thrust 
under Poupart's ligament overrode the margin of the pelvis in such a 
manner as to underlie the femoral artery ; it remained unreduced for two 
months, when he came under observation with a diffused swelling occu- 
pying the groin, filling the iliac fossa, and extending to the middle of the 
thigh ; feeble pulsation ; tumor appeared a few days after the accident ; 
pain severe ; diagnosis, aneurism ; treatment, ligature of the common 
iliac artery ; death on fifth day." The femoral and external iliac arteries 
were perforated to the extent of an inch on the postero-external aspect ; 
the head of the femur lay in the cavity of the aneurism. 

Cases also have been reported of rupture of the anterior and posterior 
tibial arteries in dislocation of the ankle ; and Sedillot 2 published one in 
which the brachial artery w T as ruptured at the elbow by being stretched 
over the end of the humerus in a dislocation of the radius and ulna 
backward. 

Nerves. — Injuries of the nerves may be demonstrated by direct 
examination or inferred from the symptoms. Examples of the former 
are uncommon, and in some of the latter it may remain in doubt whether 
the nerves were injured by the displacement of the bone, or by the efforts 
to reduce the dislocation, or by the independent action of the violence 
upon them. It is asserted 1 that a fall upon the hand or shoulder, without 
lesion of the skeleton, is competent to cause palsy of the arm ; hence, it 
is not always to be inferred that a palsy following a dislocation has been 
caused by the pressure of the head of the bone upon the nerves, and this 
is especially true of those cases in which a blow has been received 
directly upon the shoulder, and the deltoid alone is paralyzed. 

The injury may be a complete rupture or laceration of one or more 
nerve trunks, or a contusion with extravasation of blood about the nerve 
and amid its fibres, or a neuritis originating in. an injury of some lesser 
nerve and extending thence to the main trunk, or an inflammatory pro- 
cess extending to the nerve and causing its compression by newly formed 
connective tissue, or simple compression by the displaced bone. 

Rupture or laceration of the nerve is caused by violent pressure 
against it of the displaced end of the bone, and, in the case at least of 
the larger trunks, it appears commonly to be associated with extensive 
laceration of the other soft parts, including even the overlying skin. 
Contusion of the nerve may be produced in the same manner, and then 
represents a less degree of the same injury, or by compression of the 

1 Goldsmith: Amer. Journ. Med. Sciences, Jul}', 1860, p. 30; abstract from 
Louisville Med. Journ., February, 1860. 

2 Sedillot: Diet. Encyclopedique, art. Luxations, p. 261. 

3 Weir Mitchell : Injuries of Nerves, p. 99. 



36 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

nerve between the displaced bone and an adjoining portion of the skeleton, 
as between the head of the humerus and the wall of the thorax. 

The symptoms vary with the character of the injury; laceration is 
immediately followed by motor paralysis and loss of sensation in the 
region supplied by the nerve which are permanent or persist until the 
integrity of the nerve is restored ; in the others there are varying 
degrees of paralysis and loss of sensation, numbness, pain, alteration of 
local nutrition, and other symptoms of neuritis, limited at first to the 
nerve directly injured, and afterward perhaps extending to others. In 
many of the recorded cases a cure has followed the systematic use of 
electricity. 

The relative frequency of the occurrence of this complication at the 
shoulder is indicated in the statistics of the Friedrich's Hospital, col- 
lated by Holm ; l of 112 cases of dislocation of the shoulder there was 
general paralysis of the arm in 7, and paralysis of the deltoid alone in 
10. In one of them all the muscles supplied by the median nerve were 
paralyzed, while those supplied by the musculo-spiral were unaffected. 

The recorded cases of rupture of a nerve verified by direct examina- 
tion are few ; the following are examples of different forms : 

Hilton 2 examined the body of a man who died thirteen weeks after 
having received a dislocation of the shoulder into the axilla ; the deltoid 
was much atrophied, the circumflex nerve was small and was " distinctly 
lacerated, but its actual condition was changed by some strong cellular 
adhesions, fixing it with the radio-spinal nerve and the axillary artery to 
the inner surface of the subscapularis muscle." Bouley 3 presented to the 
Societe Anatomique a specimen of complete dislocation outward of both 
bones of the forearm at the elbow, with fracture of the outer condyle of 
the humerus, caused by a fall upon the elbow from a height of twenty- 
four feet. The patient refused amputation and died twenty days after 
the receipt of the injury. " The lateral ligaments of the elbow were 
entirely ruptured, both bones of the forearm were situated external to 
the lower end of the humerus, and the ulnar nerve was lacerated at the 
level of the articular surface." 

Holl 4 found in the dissecting room a cadaver with a marked deformity 
of the elbow, and on examination it appeared that the individual had 
suffered fracture of the upper end of the ulna and dislocation of the head 
of the radius upward and inward, and that the ulnar artery and ulnar 
and median nerves had been completely divided and had not reunited. 

Boyer is commonly quoted as having seen the median nerve ruptured 
5n a compound dislocation at the elbow, but his reference to the case 5 has 
apparently been misunderstood. He speaks of rupture of the brachial 
artery, and says he cannot conceive how the median nerve could escape. 
The injury was followed by gangrene of the limb and the death of the 
patient. 

1 Holm : Schmidt's Jahrbuch, vol. 121, p. 82. 

2 Hilton : Guy's Hosp. Reports, 1847, vol. 5, p. 98. 

8 Bouley : Bull, de la Soc. Anatomique, 1837, p. 101. 

4 Holl: Medicin. Jahrbuch, Wien, 1880, p 151. 

5 Boyer : Traite des Malad. Chirurgicales, 4th ed. vol. 4, pp. 317 and 322. 



PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 37 

In a case reported by Ferret, 1 a compound dislocation of the elbow in 
which the bare end of the humerus projected two inches through a wound 
on the antero-inner aspect of the joint, the brachial artery was ruptured 
and the median nerve was exposed for a distance of three or four inches 
and was tightly stretched across the wound. Six days later all the 
denuded portion of the nerve had become gangrenous. The patient, a 
boy, fourteen years old, recovered with full use of the muscles and unim- 
paired sensibility in the region supplied by the median nerve. This 
restoration was attributed to an anastomosis between the median and 
ulnar nerves ; electrical stimulation of the latter in the arm caused the 
flexor muscles of the forearm to contract. 

Of the cases that have been observed clinically the injury in most has 
been attributed to the reduction, as a consequence of too forcible traction, 
extreme abduction of the limb (arm), or to the presence of adhesions 
between the nerve and the parts with which it has been temporarily 
brought into contact. In some of these cases the correctness of this view 
cannot be questioned ; in others the necessary data for an opinion are 
lacking. 

A man 2 fifty-four years old was seized by the right arm and shaken so 
violently as to dislocate the humerus into the axilla, causing pain in the 
shoulder and instant loss of feeling and motion in the hand. Reduction 
on the third day. " Six weeks afterward the whole hand and lower side 
of the forearm were oedematous, and the former also hard and brawn-like, 
resisting pressure. The fingers were in the same state, and the whole 
hand was dark and congested, but not shiny or smooth. The joints from 
the wrist to the finger ends were sore, swollen, and very stiff. The 
whole palm was the seat of pretty severe burning, with no darting or 
other pain." Partial loss of touch and pain-sense in the median and 
radial distribution. The elbow motions were perfect, wrist flexion good, 
extension lost ; flexion of the fingers good, extension and lateral motions 
lost from palsy of the extensors and interossei. 

A soldier 3 fell from a tree, striking upon and dislocating his left shoulder ; 
the dislocation was reduced within twenty-four hours, and, the previous 
pain and numbness disappearing, he remained well for four weeks, when 
the arm began to waste, with loss of power which became complete in a 
few months. Sensation was much less altered. At the close of a year 
there was only partial ability to flex the arm, and slight use of the flexors 
and extensors of the fingers. Marked atrophy ; contraction of the pro- 
nators. Rapid relief and final cure were obtained by electricity. 

A man 4 twenty-five years old was admitted to the Hotel Dieu with an 
intracoracoid dislocation of the left shoulder, caused shortly before by a 
fall. Any motion communicated to the limb caused great pain and vio- 
lent involuntary contraction of all its muscles. The next morning the 
dislocation was found to have become subglenoid, the limb was. completely 
paralyzed, but without loss of sensation, and although communicated 
motion was still painful, it did not cause reflex contractions of tho 

1 Ferret: Le Proves Med., May 7, 1887. 

2 Weir Mitchell, Injuries of Nerves, p. 103. 

3 Weir Mitchell, loc. cit., p. 101. 

4 Duchenne : De l'Electrisation localised, 2d ed., p 179. 



38 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

muscles. Reduction was readily effected with the aid of anaesthesia. 
The muscles of the shoulder reacted to the faradic current ; those of the 
arm and forearm did not. The limb wasted rapidly ; under electrical 
treatment an almost complete cure was obtained in about two years. 

Rothe 1 reported a case of suprapubic dislocation in a girl fifteen years 
old, in which, three weeks afterward, the extensors of the leg upon the 
thigh were found to be paralyzed. The case is quoted by Kronlein as an 
instance of pressure upon the anterior crural nerve, but Rothe attributes 
the disability to extreme flexion of the knee at the time of the accident. 
Kronlein (loc. cit., p. 34) also quotes Hutchinson as having seen paralysis 
of the sciatic nerve follow an ischiatic dislocation of the femur ; and Sir 
Astley Cooper (loc. cit., p. 67) quotes a case in which numbness of the 
limb accompanied the same injur}^. Cooper (loc. cit., p. 74) also quotes 
a case of suprapubic dislocation in which the pressure of the head of the 
femur upon the anterior crural nerve caused numbness of the thigh ; 
pulsation was also arrested by the pressure of the head of the bone upon 
the artery. 

The tetanus which has been occasionally observed after dislocation, 
especially after compound dislocation of the fingers, may provisionally 
be classed among the results of injury of the smaller nerves. 

Viscera. — Excluding the common implication of the spinal cord in 
dislocations of the vertebrae, there are few recorded cases of injury to 
parts lying within the body or neck by dislocated bones. Such injuries 
must, to a greater or less extent, accompany dislocation of the head of the 
femur through the floor of the acetabulum into the pelvis, and complete 
dislocation backward of the sternal end of the clavicle has in some cases 
been accompanied by symptoms indicating pressure on the trachea or 
oesophagus. In one case 2 this pressure upon the oesophagus was so great 
as to lead to an operation for its relief. The patient, a woman, "had a 
great deformity, arising from a distorted spine, increased by an accident 
which displaced the sternal extremity of the left clavicle and threw it 
behind the sternum. The progressive distortion of the spine gradually 
advanced the scapula, and occasioned the sternal end of the clavicle to 
project inward, behind the sternum, so as to press upon the oesophagus 
and occasion extreme difficulty in deglutition. Her deformity had become 
excessive, and her emaciation extreme." The sternal end of the bone 
was removed by operation ; the patient survived six years " and recovered 
considerably from her former emaciation." 

A case that is entirely unique, and interesting not only because of the 
distance to which the bone was displaced, but also because of the changes 
subsequently undergone by the bone, and of the ease with which the 
deformity was borne, is reported by Prochaska 3 and by Larrey, 4 who had 
examined the specimen. A lad, sixteen or seventeen years old, dislocated 
his right humerus by a fall upon the abducted elbow, and the head of the 
bone was driven between the second and third ribs (Prochaska says the 

1 Rothe : Deutsche Klinik, 1868, No. 38, p. 343. 

2 Sir Astley Cooper, loc. cit., p. 309. 

3 Prochaska: Disquisitio Anatomico-physiol. Org. Humani. Wien, 1812, quoted 
by Malgaigne. 

4 Larrey: Mem. de Chir. Militaire, vol. 2, pp. 405-107. 



PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 39 

third rib was fractured) into the chest, stripping up the pleura, but not 
perforating it. All attempts to reduce it were unavailing, and the subse- 
quent treatment was limited to venesection, warm baths, and antiphlo- 
gistic measures for the relief of urgent symptoms. The patient survived 
until the age of thirty-one (forty, Prochaska), and, although the arm 
remained abducted, gained his livelihood by woodchopping. At the 
autopsy the head of the humerus was found within the thorax, covered 
by the pleura, and its neck firmly placed between the second and third 
ribs. The head was so soft that it yielded to the slightest pressure of the 
finger ; the articular cartilage and bony texture of all the portion that 
lay within the chest had entirely disappeared, leaving only a few mem- 
branous remains of the humerus, of which the greater part seemed to 
belong to the costal pleura. Prochaska describes it as "naked, soft, 
yielding to the softest pressure, presenting only a thin envelope, and 
almost empty within, since it had lost more than half of its internal bony 
substance." 

Soft Parts and Integument (compound dislocations). — Although 
instances of this complication have been recorded for almost every joint, 
they are yet of rare occurrence, and mainly restricted to the elbow, knee, 
ankle, and phalanges. Except in the latter case, they are commonly the 
result of extreme violence, and the wound of the skin is produced either 
by the direct action of this violence, or from within outward by the pro- 
jecting end of the bone. 

The complication in the case of the larger joints is very grave, because 
of the extent of the injury, which is usually great and marked by much 
laceration and bruising of the tissues, and also because of the special 
dangers due to the contact of the air with the wound. It is hardly to be 
expected that even with the most careful and skilful treatment the wound 
will heal without suppuration, and even if this suppuration should fail to 
invade the joint, and thus imperil life, it is quite certain so to modify the 
periarticular tissues as to limit the range of motion and impair the use- 
fulness of the limb. 

The treatment may require, in addition to the most rigorous antiseptic 
measures, the partial excision of the joint, because of the difficulty of 
otherwise providing efficient drainage of all the recesses and pouches of 
the synovial sac. The injury, in a word, has much in common with gun- 
shot wounds of joints, and shares their well-known gravity. To what 
extent the results of former experience will be improved upon by those 
of modern methods, remains to be determined ; it can only be said that 
the promise is good, and that it is sustained by some excellent cures 
already obtained. 

Most systematic writers upon the subject assert that there is no recorded 
case of compound dislocation of the hip, and account for the fact bv the 
thickness of the soft parts that overlie this joint, and the resistance they 
oppose to the displacing violence. Yet there is a case recorded in full in 
Bransby Cooper's edition of Sir Astley Cooper's work (case 63, p. 80), 
and briefly mentioned by Hamilton. It was communicated to Cooper by 
Dr. Walker, of Charlestown, Mass. The patient, a very muscular man, fell 
under a wagon, the wheel passing " over the posterior part of his pelvis 
and right thigh, forcing the head of the femur out of the acetabulum 



40 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

forward upon the groin, lacerating the soft parts, and pressing the head 
through the integuments." After several attempts to reduce by traction, 
the bone was replaced by manipulation. Extensive suppuration followed, 
and the patient died at the end of about three weeks. Case 61 of the 
same author, although not described as such, appears at least to have 
become compound, if not originally so. 

Another case is contained in the statistical Sanitary Report of the 
Fourteenth Prussian Army Corps for the period from 1874 to 1878. l A 
mounted artilleryman, while galloping, fell with his horse in front of the 
gun, and his left leg was bent back so violently that the heel lay against 
the back of the shoulder, and the head of the femur with the torn liga- 
mentum teres projected through the fold of the groin. There was profuse 
bleeding from the femoral vein, and the man died within twenty-four 
hours. For additional cases, see Chapter XXV. 

Compound dislocations of the shoulder also are rare, those of the elbow 
and knee less so, and those of the smaller joints much more frequent. 
When at the elbow or knee the wound is made by the projecting end of 
the humerus or of the femur in the flexure of the joint, the overlying 
artery can hardly escape rupture. 

Repair — Only a few observations have been made of simple disloca- 
tions undergoing, or that have undergone, repair. Clinically it is known 
that, after a period of a few days or weeks marked by gradually dimin- 
ishing tenderness and swelling, the joint can be freely used without pain, 
but that sometimes the range of motion remains limited for a much longer 
period, and that in some cases there is a marked tendency to recurrence 
of the dislocation. In a few cases, in which patients have died within a 
few days after having suffered a dislocation, the surrounding tissues have 
shown the remains of the extravasation of blood that had taken place 
amid them, and the rent in the capsule has either been occupied by a 
clot, or has been empty and without evidence of repair. It is to be 
presumed, however, that repair usually takes place after dislocation, as 
it does after many other subcutaneous injuries, without suppuration or 
even much inflammatory reaction, that the ruptured capsule reunites or 
that the gap in it is filled by condensation and adhesion of the adjoining 
connective tissue, that the lacerated muscles and ligaments are repaired 
in like manner, and that these cicatrices pursue the evolution common to 
their class. 

This process may, however, be disturbed by various complications. If 
the injury has been exceptionally severe, if the bone has been widely 
displaced, and the surrounding tissues much lacerated, if the efforts to 
reduce have been violent and long continued, if the joint has not been 
properly immobilized, if passive motion has been injudiciously begun and 
maintained, or, finally, if the general condition of the patient is unfavor- 
able for repair, the inflammatory reaction may become excessive, and 
even end in suppuration and pyaemia. If it stops short of this disastrous 
result, it may yet lead to partial or complete ankylosis through the forma- 
tion of adhesions between the opposed articular surfaces or the thickening 
and retraction of the capsule and periarticular tissues. The older records 

1 Abstract in Centralblatt fur Chirurgie, 1880, p. 504. 



PATHOLOGICAL ANATOMY IN" RECENT DISLOCATIONS, 



41 



Fig. 1. 



contain numerous instances in which suppuration appears to have been 
caused by the efforts to reduce, but this accident has become much less 
common since the introduction of anaesthesia and the substitution of the 
so-called "mild" methods by manipulation for the forcible traction by 
pulleys which was formerly so much in vogue. In the following cases 
reported by Cooper, 1 it does not appear whether or not the reduction was 
a controlling factor in exciting the suppuration. 

"A man had his thigh dislocated upward and backward on the ilium,, 
which was soon after reduced ; the next day a considerable swelling was 
observed in the part, which continued to increase, accompanied by rigors, 
and in four days the patient died. On dissection, the capsular ligament 
and ligamentum teres were found .entirely torn away, and a considerable 
quantity of pus extravasated in the surrounding parts." " I attended 
the master of a ship, who had dislocated his thigh upward ; an extension 
was made, apparently with success ; but in a few days a large abscess 
formed in the thigh, which destroyed the patient." 

Fractures of apophyses, or portions of bone to which muscles or liga- 
ments are attached, are repaired either by bony callus or by a fibrous 
band, the difference depending on the extent of the separation and the 
independent motion of the fragment. The fragment may be withdrawn 
to such a distance that the attached muscle or muscles permanently cease 
to exercise any control over the 
main bone, which, in consequence, is 
exposed to frequent and easy recur- 
rence of the dislocation. The same 
infirmity may result from defective 
repair of fracture of the rim of an 
orbicular cavity. Instances of the 
former variety are most common at 
the shoulder-joint, those of the latter 
are found at the hip and shoulder. 
The existence of a marked liability 
to recurrent dislocation (Fig. 1) is 
often found at the shoulder, and its 
explanation has been recently fur- 
nished by Jossel, ] who had the oppor- 
tunity to examine four such cases 
after death ; he found in all that the 
supraspinatus and infraspinatus mus- 
cles had been torn loose from their 
attachment to the greater tuberosity, 
had retracted behind the acromion, 
and had undergone atrophy and fatty 
degeneration. The relations of the 
tendons of these muscles with the 
articular capsule are so close that 
the rupture of the former involves also that of the latter, and the 
retraction of the former creates, by drawing back one side of the rent, a 




Kecurrent or habitual dislocation of the shoul- 
der, showing the opening into the subacromial 
bursa. (Jossel ) 



1 Loc. cit., p. 4. 

2 Jossel: Deutsche Zeitschrift fiir Chirurgie, 1880, vol. xiii. p. 167. 



42 PATHOLOGICAL ANATOMY IN RECENT DISLOCATIONS. 

large gap in the upper part of the capsule opening into the subacromial 
bursa. In the process of cicatrization the front part of the capsule, 
that lying between its attachment to the humerus and the rent, becomes 
adherent at the edge of the rent to the under surface of the deltoid close 
by its attachment' to the acromion, while the posterior lip of the rent, 
after retraction with the tendon, becomes permanently fixed at the poste- 
rior part of the acromion. The under surface of the acromion is thus left 
to fill the gap between the two lips, to form the upper limit of the artic- 
ular cavity, and to be in direct contact with the head of the humerus. 
In none of Jossel's four cases was the normal communication between 
the cavity of the joint and the subscapular bursa found to be enlarged; 
in one the subcoracoid bursa communicated with the joint, and in one the 
tendon of the long head of the biceps was ruptured, and its torn end had 
become fixed in the bicipital groove. In two of the cases a small defect 
with smooth edges was found in the capsule below the tendon of the sub- 
scapularis, and in the others the capsule appeared thinned at the same 
point. Apparently this indicated the place at which the head of the 
humerus escaped through the capsule at the time of the first dislocation. 

The cavity of the joint was greatly enlarged by these changes in the 
capsule; in the first its capacity was 90 cubic centimetres, as against 28 
in a normal joint, and its length along the upper portion 10 centimetres 
instead of the normal 3f. 

This condition of the capsule, and especially the withdrawal of the 
control and support normally supplied by the supraspinatus and infra- 
spinatus muscles, seem entirely adequate to explain the easy recurrence 
of the dislocation. 

It has been observed in some cases of old, and even unreduced, disloca- 
tions of the shoulder, that the broken portions of the greater tuberosity 
have reunited with the humerus, and as this fracture is much more 
common than the alternative lesion of rupture of the tendon, as, indeed, 
it is thought to be an almost constant accompaniment of the dislocation, 
it is evident that the latter lesion, rupture of the tendon, is much more 
likely to be followed by a tendency to recurrent dislocation, presumably 
because the broken fragment of the tuberosity remains attached to the 
humerus by the periosteum, while there is nothing to oppose the retrac- 
tion of the torn tendon. 

G-angrene of the limb may ensue upon the rupture of the principal 
vessels, or even upon extensive laceration and violent inflammatory reac- 
tion ; and paralysis of one or several muscles may manifest itself imme- 
diately or only after the limb is again brought into use, the result of 
injury to nerve trunks or of contusion of the muscle itself. 



CHAP TEE IV. 

THE PATHOLOGY OF UNREDUCED ("ANCIENT," "INVETERATE") 
DISLOCATIONS. 

The changes that take place about joints that have long remained 
dislocated are well understood, through direct observations of many speci- 
mens in man and through experiment upon animals. These changes are 
partly the direct result of purely inflammatory processes excited by the 
traumatism and the changed relations of the parts, partly that of disease, 
and partly that of a seeming effort of nature to create a new and serviceable 
joint. Striking as the latter sometimes is, it is not to be supposed that 
the organism possesses and is stimulated by the changed conditions to 
exert a creative or formative power similar to that existing in the impreg- 
nated ovum or even to that of certain batrachians by which a lost limb 
can be reproduced ; the changes are all the result of properties normally 
possessed by the connective tissues and habitually stimulated to activity 
by unwonted irritation, the powers of multiplication, growth, and trans- 
formation. The changes consist, in general terms, in the condensation 
and thickening of connective tissue about the displaced bone in such a 
manner as to protect it against farther displacement, and in the change 
of the bones at the new points of contact partly by absorption and partly 
by the formation of new bony outgrowths through continued slight irrita- 
tion of the bone itself, the periosteum, and the adjoining fibrous and 
ligamental tissues. The irritation which leads to these changes is fur- 
nished by motion, use, of the limb ; hence the most striking examples 
are found at the shoulder and the hip, and these will be used as the basis 
of the following description : 

The first changes, in point of time, are those in the bruised and torn 
soft parts amid which the end of the bone has lodged after its escape 
through the rent in the capsule. The loose connective tissue lying about 
the vessels, nerves, and muscular bundles, bruised and pressed back by 
the head of the bone and infiltrated with extravasated blood, reacts in the 
usual manner under the traumatism by becoming the seat of an exudation 
and by multiplication of its cellular elements. The latter follow their 
natural evolution into fibrous tissue, and thus is formed about the bone a 
continuous fibrous envelope enclosing a cavity within which the end of 
the bone lies, more or less free, and continuous structurally on its outside 
with the adjoining tissues, some of which — vessels, nerves, and muscular 
fibres — may be firmly imbedded in it. Its inner surface is smooth and 
lined with flat cells resembling those found on the surface of normal or 
accidental bursse, and it is moistened by a small amount of liquid which, 
in some cases, closely resembles synovia. It seems probable that when 
real synovia is present it is furnished by portions of the original capsule 



44 PATHOLOGY OF UNREDUCED DISLOCATIONS. 

which have remained adherent to the bone and have formed part of the new- 
cavity. 1 Indeed, the new cavity is usually only an enlargement of, or 
addition to, the original one ; its connection with, or its entire indepen- 
dence of, the old one is determined by the character and extent of the 
rent in the capsule and the distance to which the head of the bone has 
passed through it. If the head of the humerus, for example, has passed 
entirely through the rent and the capsule is widely torn away from the 
humerus, its freed, torn portion may slip in between the bone and ' the 
glenoid cavity and completely shut off the latter by contracting new adhe- 
sions along its torn edge ; or, as in the case described by Thore, 2 the 
outer portion of the capsule may be drawn across the face of the glenoid 
cavity, and, uniting with the torn tissues on the inner side of the latter, 
shut it off entirely from the cavity of the new capsule. But in the great 
majority of cases a sufficient amount of the capsule remains untorn to 
insure the continuity of the new cavity with the old one, although the 
communication between them may be small and the torn portions may 
have become so fixed in an intermediate position as to create an insur- 
mountable obstacle to reduction. Another obstacle is found in the new 
and strong bands formed by the condensed tissues between the bones, 
bands often of great strength and thickness because the adjoining tissues, 
of which they are primarily composed, are matted together and supple- 
mented by others of inflammatory origin. In many of the far too fre- 
quent cases in which death has been caused by an attempt to reduce an 
ancient dislocation the post-mortem examination has shown the dislocated 
bone so firmly bound in its new position that it could not have been 
reduced without lacerations far in excess even of the fatal ones occasioned 
by the unsuccessful attempt. 

But while these changes in the soft parts tend permanently to fix the 
bone in its new position, other changes take place in the periosteum and 
the bone itself upon which the displaced articular end rests and moves, 
which, on the other hand, tend to make this new position a more suitable 
resting-place and to give it a form and character like those of the part it 
is to replace. Thus, a new cotyloid cavity may be formed upon the 
dorsum of the ilium, or a new glenoid cavity on the inner side of the 
scapula adjoining the old one. In this new formation of bone two 
processes may take part — production of bone by the periosteum, and 
ossification of the old ligaments and new fibrous tissue. The periosteum 
may produce bone either after it has been stripped up or while it is still 
in place. If, in the dislocation of the head of the bone, a portion of the 
rim of the corresponding articular cavity is broken off and pushed away, 
carrying with it a strip of periosteum torn from the adjoining surface, 
but preserving its connection with both pieces, this loosened strip forms 
on its side the limit of the new cavity, and produces on its under surface 
new bone which is continuous with the old and with the fragment of the 
rim, constituting a bridge between them. Fig. 2 shows a new cotyloid 
cavity of which the upper portion seems to have been formed in this 
manner. 

1 Yet in some cases of pseudarthrosis following fracture of the shaft of a hone a 
similar liquid has been found in the cavity of the false joint. Fractures, p. 199. 

2 Thore: Bull, de la Soc. Anatomique, 1839, p. 33. 



PATHOLOGY OF UNREDUCED DISLOCATIONS 
Fig. 2. 



45 




Old supracotyloid dislocation of the femur, with very complete new acetabulum. From the collection 

at Bonn. (Kronlein.) 

If the periosteum is not stripped up, but the head of the bone escapes 
entirely from the cavity and comes to rest upon the outside of a layer of 
periosteum still adherent to its bone, this periosteum, irritated by the 
pressure and movements, produces new bone between itself and the old, 
and this production is greatest in the 
zone just around the point of greatest 
pressure. The portion of periosteum 
directly pressed upon disappears under 



Pig. 3. 



; % 



leaving 



a bare surface of 



: S 'WV r^^^^^K 



the pressure, 

"bone in contact with the displaced head, 
or becomes fibrous or fibro-cartilaginous 
in structure; while in the immediately 
adjoining portion the osteogenetic prop- 
erty is called into play and a ridge or rim 
of bone is built up around the central de- 
nuded area. Sometimes the denuded 
"bone is worn away or disappears by ab- 
sorption under the influence of the 
pressure ; but this is rare, and the ap- 
pearance of erosion is deceptive, being 
given by the elevation of the surrounding 
part. This elevation may be a sharply 
defined rim rising to a considerable 
height and closely resembling that for which it is a substitute, or it may 
be a mass of irregular height and outline (Fig. 3), having little or no 
resemblance to either the glenoid or cotyloid cavity. 




Scapula showing new socket found in 
an old unreduced subcoracoid dislocation. 
(Cooper. ) 



46 PATHOLOGY OF UNREDUCED DISLOCATIONS. 

The details of this formation, as observed by Baiardi 1 at the hip in 
animals, consist, first, in the appearance of a circular cartilaginous wall 
whose free border is continuous with the new-formed fibrous capsule, its base 
resting upon the ilium and its inner surface in contact with the head of the 
femur ; its ossification (in rabbits) is complete by the thirtieth day, except 
along its concave surface, where it remains soft, shading off toward the 
centre of the new acetabulum into a whitish, cartilaginous-like tissue, 
which takes the place of the destroyed periosteum. On its free border it 
has the structure of fibro-cartilage ; on the concave surface it closely 
approximates that of hyaline, articular cartilage. At the very centre, as 
above said, the underlying bone is left bare or is covered by fibrous tissue 
and fibro-cartilage, and becomes denser in structure. Grinewetsky, 2 who 
experimented on dogs, says he never found a lining of periosteum or 
cartilage inside the new acetabulum ; the bone was always sclerosed. He 
also notes the absence of endothelium on the inner surface of the new 
capsule. 

The ossification may pass beyond the usual limits and include portions 
of the capsule, 3 forming bony stalactites, or even a complete bony case 
enveloping, and perhaps united with, the head of the bone ; 4 and in a 
specimen presented by Moreau, 5 a dislocation of the femur into the 
obturator foramen, the membrane filling the foramen had been trans- 
formed into a bony plate throughout, except in a strip along its anterior 
margin. 

Some of these experimental observations have been repeated upon 
specimens of ancient dislocations in man, in some of which the new cavity 
has been found to be lined with fibro-cartilage, 6 in others with a granular 
fibroid tissue without apparent cartilage of incrustation. 7 

The displaced head shows changes varying in extent and consisting in 
loss of its cartilage, erosion of the bone in places and its increase in 
others, and occasionally in profound changes of structure throughout. 
Thus in the case just referred to, reported by Duguet, a dislocation inward 
of the shoulder of six months' standing, the head of the humerus was 
worn away behind at the point where it rested against the rim of the 
glenoid cavity, which also had in great part disappeared ; its anterior 
portion had preserved its cartilage at almost all points, while its posterior 
portion had none, it being there replaced by rather tight, short fibrous 
bands uniting the head to the old glenoid cavity. In Lepine's case, a 
subcoracoid dislocation, the head of the humerus was considerably 
enlarged, with a deep vertical groove on its posterior surface corresponding 
to the outer edge of the new glenoid cavity, partly bare, partly covered 
by a fibrous layer. In a specimen presented by Walsh to the Royal 
Surgical Society of Ireland, 25th April, 1840, 8 of an old dislocation of 

1 Baiardi : Arch, per le Scienze mediche, 1880, vol. iv. ; quoted by Ivronlein. 

2 Grinewetsky: Centralblatt fur Chirurgie, 1879, p. 279. f , 

3 Thore: Bull, de la Soc. Anatomique, 1839, p. 33. 

+ Cooper: Loc. cit., p. 50; and Cruveilhier : Anat. patbol., vol. i. p. 425. 

5 Moreau: Mem. de i'Acad. royale de Chirurgie, 1769, vol, ii. p. 153. 

6 Lepine and De>ormeaux, in Bull, de la Soc. Anat., 1844, p. 167. 

7 Duguet: Bull, de la Soc Anat., 1863, p. 144. 

8 Walsh : Gazette des Hopitaux, 1840, p. 320. 



PATHOLOGY OF UNREDUCED DISLOCATIONS. 



47 



the shoulder forward, the subscapulars muscle was raised from the 
scapula by the head of the humerus, the new glenoid cavity was covered 
by fibro-cartilage, the synovial sac was complete, and the cartilage of the 
humerus perfect. 

The empty glenoid or cotyloid cavity diminishes gradually in size 
either by absorption of that portion against which the head of the bone 
rests or by a general atrophy, presumably due to its disuse, similar to 
that observed in the alveolar process after removal of the teeth, and its 
cavity fills up with fibrous tissue that springs from and replaces its lining 
cartilage. The glenoid cavity has in some cases been still further ren- 
dered unfit for use and inaccessible by union with the outer portion of 
the original capsule, when that has been drawn across its face as the 
humerus was displaced inward. In a case reported by Hilton, and 
referred to in Chapter III., in which death followed thirteen weeks after a 
dislocation of the shoulder which could be reduced with great facility 
but constantly recurred, the anterior and inner portion of the capsule was 
found interposed between the head of the humerus and the glenoid 
cavity, and the centre of this interposed portion had been thinned and in 
part absorbed in consequence of the pressure ; apparently, if the patient 
had lived all the interposed portion would have been absorbed and the 
natural relations between the articular surfaces would have been restored. 



Fig. 4. 







Old unreduced dislocation of the right humerus, with interposition of the capsule, At the inner side of 
the head of the humerus is the rent in the capsule through which it passed, and above the rent is the 
greater tuberosity which had been torn off. At the outer side of the coracoid process is an opening in the 
apsule which had been produced by the pressure of the humerus ; through it the glenoid fossa is seeiu 
(Hilton.) 



When the use made of the limb is very slight and the head of the bone 
is immovably fixed in its new position, the development of articular 
characteristics is slighter and the bone may even diminish notably in size 



48 PATHOLOGY OF UNREDUCED DISLOCATIONS. 

or consistency, as in the case quoted in Chapter III. in which the head of 
the humerus passed into the chest and remained fixed there. This atrophy 
of disused parts is a general rule, and although observed in bone is more 
marked in other tissues whose nutritive changes and functional activity 
are greater. In accordance with this general law the muscles which are 
rendered inactive by the greater or less fixation of the dislocated bone 
diminish in size, and if their inactivity is complete, or even nearly so, 
their fibres undergo an actual degeneration and their fibrous tissue pre- 
dominates to such an extent that they are hardly more than ligaments. 
The bone, too, is similarly affected throughout its entire length ; it 
becomes smaller, or, if the dislocation has occurred during youth, before 
development is complete, fails to develop to the same extent as its fellow 
on the opposite side, and even its normal curves disappear. 

These facts show both the danger and the futility of attempts to reduce 
dislocations that have long existed ; they show that the reduction can be 
accomplished only at the cost of lacerations far more extensive than those 
involved in the original injury, that among these lacerations may be 
included rupture of important vessels or nerves that have become 
adherent to or included in the fibrous bands of new formation, and that 
even if the bone can be successfully liberated from its attachments and 
brought back to the cavity from which it was displaced the latter may 
have become entirely unfit for its reception and for a resumption of its 
own original functions. Such a " reduction " is illusory, and its advan- 
tages are in no manner commensurate with the dangers incurred in the 
effort to obtain it. 

Important changes in the condition of the limb may be caused by 
pressure upon the bloodvessels or nerves by the displaced bone or by 
injury done them during attempts at reduction. Instances of the latter 
will be given in Chapter VIII. 

A unique case of degeneration of all the tissues of the limb following 
a subcoracoid dislocation of the shoulder that had remained unreduced 
for three months was reported by Guerin. 1 The patient was a woman 
sixty-three years old, and when brought to Guerin three months after 
the occurrence of the dislocation was unable to use any of the muscles 
of the limb, except to make slight movements of the fingers ; its tem- 
perature and circulation were unaltered. Reduction was attempted, with 
the aid of chloroform, by having four men make traction by means of a 
band attached to the wrist, counter-extension being made by a band 
passed under the axilla. Suddenly the forearm was torn completely 
away, the separation taking place at the elbow-joint and leaving a por- 
tion of the olecranon attached to the tricips. The patient died of 
septicaemia in the second week. Examination of the limb showed great 
friability of the muscles with degeneration of their tissue and of their 
nerves, and rarefaction of the bones which had made them so friable that 
the radius and ulna had been broken by the pressure of the band at the 
wrist. The changes were apparently due to the pressure of the head of 
the humerus upon the nerve trunks, the degeneration of which extended 
a little above the point at which they were pressed upon. The other 

1 Guerin : Bull, de la Societe de Chirurgie, 1864, pp. 121 and 131. 



PATHOLOGY OF UNREDUCED DISLOCATIONS. 49 

bones, muscles, and nerves of the body were normal. The axillary 
vessels were not pressed upon. 

Persistent oedema, resulting in a condition resembling elephantiasis, 
was observed by Bartels 1 in a patient whose shoulder had been dislocated 
for more than a year. There was also rigidity of the fingers in a posi- 
tion indicating ulnar paralysis, which was relieved by increasing the 
mobility of the shoulder, but the oedema persisted. 

1 Bartels : Arch, fur Klin. Chir., 1874, vol. 16, p. 688. 



CHAPTEE V. 



SYMPTOMS AND DIAGNOSIS. 



The symptoms of a dislocation — those changes in the form, functions, 
and sensibility of the part by which the presence of a dislocation is 
recognized — are classed as objective and subjective or rational. The 
former, which alone are deemed demonstrative, are those which can be 
recognized by the surgeon on examination ; the latter are those for his 
knowledge of which he must depend, to a greater or less extent, upon the 
statements of the patient. 

The examination of the patient should always be conducted systemati- 
cally, with the view to learn not merely the existence of the dislocation, 
but also such details and complications as may be present, and may affect 
the treatment and prognosis ; and it should include an examination of 
the condition of such bloodvessels and nerves as may have been injured 
at the same time, in order that such injuries, if their later consequences 
should become manifest, may not be attributed to the treatment. If 
swelling, a large amount of subcutaneous fat, or pain should prevent a 
satisfactory examination, anaesthesia should be employed. The character 
and direction of the force that produced the dislocation should be learned, 
and also, if possible, the position of the limb at the moment of its disloca- 
tion, and whether a " consecutive" has been substituted for a " primary " 
displacement, or, as evidence of the latter fact, whether one fixed position 
of the limb has been substituted for another. In doubtful cases the un- 
injured limb should be used for comparison, and the question should be 
asked whether or not the suspected joint has been previously the seat of 
disease or injury the consequences of which may affect the conclusions 
to be drawn from the examination. The essential point in the examina- 
tion is to determine the position of the end of the bone, its relations to 
that one from which it is thought to have been violently separated, and 
the best evidence of this fact is furnished by feeling the end of the bone 
with the fingers, by tracing its outline, by feeling it move when the lower 
part of the limb is moved. 

Objective Signs. 

Deformity. — Besides the attitude of the patient or of the limb, which is 
often strikingly characteristic, the aspect of the region of the affected 
joint is changed by the inflammatory SAvelling, which may appear 
promptly or tardily and be accompanied by ecchymosis and by altera- 
tions in the depth or position of the fold of its flexure and in its normal 
depressions and prominences. Thus, in a dislocation downward or inward 
of the shoulder, the patient usually sits with his body inclined toward the 



OBJECTIVE SIGNS. 51 

affected side, the shoulder lowered, the elbow abducted, and the forearm 
flexed across the abdomen. The roundness of the outer aspect of the 
deltoid region is diminished or lost, and the subclavicular depression is 
effaced. In dislocation backward and upward of the hip the thigh is 
flexed, adducted, and rotated inward, the toes of the affected limb resting 
on the dorsum of the other foot : the gluteal fold is displaced upward, the 
trochanter is higher and more prominent, and the upper portion of the 
thigh is broadened outwardly. The swelling varies with the length of 
time that has elapsed since the injury was received, increasing for a day 
or two, remaining stationary for a variable time, and then diminishing; 
in old cases the region is atrophied. If the dislocation has been caused 
by external violence acting directly upon the region of the joint, the 
swelling is increased by the effects of the contusion, and ecchymoses 
appear more promptly than in other cases. 

The position, with reference to each other, of the articular surfaces or 
ends which constitute the joint can often be determined by palpation, and 
this, as has already been said, furnishes the most exact and positive 
evidence of the character of the injury. In joints that are not thickly 
overlaid by soft parts or masked by swelling or extravasated blood, this 
position can be readily made out, as at the knee, fingers, or even the 
shoulder ; at the hip it is easy in some dislocations — e. g., suprapubic — 
to recognize the head of the femur, in others it is much more difficult. 
At the shoulder the head of the humerus may be readily felt in the 
axilla or under the pectoral muscle, and its absence from its normal 
position is shown by ability to press the fingers under the acromion ; at 
the hip the emptiness of the cotyloid cavity cannot be so certainly de- 
termined, because of the resistance offered by the overlying muscles and 
ligaments. At the elbow, in a dislocation backward, the outline of the 
olecranon can sometimes be made out, and then its changed relations to 
the two epicondyles of the humerus in extension and flexion clearly 
indicate the dislocation ; if the head of the radius is dislocated, the 
recognition of its saucer-shaped surface furnishes absolute proof. 

If the head of the bone cannot be felt, its position (if there is no 
fracture) can be determined from that of its shaft and recognizable 
prominences or apophyses by reference to its anatomy. Thus, if the 
great trochanter can be recognized, the position of the head of the femur 
can be readily inferred by prolonging from it in imagination the neck of 
the femur in the line indicated by the position of the shaft. In like 
manner prolongation upward of the line of the lower portion of the 
humerus indicates the position of the head of the bone, and if it passes to 
the inner side of the acromion the shoulder must be dislocated or the bone 
broken. Similar inferences can be drawn at the hip from the relations 
of the trochanter to the ischio-iliac (Nekton's) line. 

The continuity of the supposed head with the shaft is determined by 
recognizing that it participates in slight movements communicated to the 
lower segment of the limb. The aid of needles passed down through the 
soft parts to the head of the bone is sometimes resorted to when the 
thickness of the soft parts makes examination with the fingers difficult or 
uncertain. By prolonged firm pressure with the fingers an inflammatory 
swelling may sometimes be pushed aside and the bone distinctly felt. 



52 



SYMPTOMS AND DIAGNOSIS. 



Fig. 5. 




Diagram to show the effect of 
position upon the apparent 
length of the arm in dislocation 
of the shoulder. A, acromion; 
B, lower end of humerus. 



The limb may appear to be, or may actually be, shortened or lengthened, 
but this sign is not of so much value as it is in cases of fracture, both 
because it varies greatly with varying positions 
of the limbs and cannot usually be determined 
with accuracy, and because the measurement is 
not of the length of a single bone, but of the 
distance betwen points or different bones. It is 
true that in fracture the measurement is often 
made from a point on one bone to a point on 
another, but the limbs can usually be placed 
symmetrically, while this is more difficult in dis- 
location. The reason why the length of the 
measured distance varies in different positions of 
the limb can be made clear by taking an ex- 
ample, as the shoulder. Here the distance 
usually measured is that from the edge of the 
acromion to the external epicondyle of the 
humerus. Now, this distance diminishes as the 
arm is abducted, for (Fig. 5) when the arm 
hangs by the side, the line A B {A being the acromion, B the external 
epicondyle, and (7 the centre of the head of the humerus) is almost exactly 
equal to CB plus the distance that lies below the level of A ; while, 
on the other hand, when the arm is abducted the distance A B' is equal 
to CB minus the distance of beyond the line of A. Similar condi- 
tions exist in dislocation at the hip, where the measurement is habitually 
made from the anterior superior spine of the ilium. In dislocation of the 
elbow a comparison of the two limbs can be more easily made and with 
less chance of error if there is no lateral deviation, since it is only neces- 
sary to have the elbows flexed at the same angle and to measure from 
the internal epicondyle to the lower end of the ulna. 
(:?, The methods of measuring and the precautions to be taken are the 
same as in the case of fracture and have been elsewhere considered ; and 
the possibility of the previous existence of asym- 
metry of the limbs, of a difference in their length, 
has also been described. (Fractures, p. 101.) 

Loss of Mobility. — As has been said, in every 
dislocation there is a position which is characteristic 
of it and which the limb tends spontaneously to as- 
sume and retain. This position depends rather upon 
the tenseness of ligaments and untorn portions of the 
capsule than upon the contraction of the muscles, 
although the latter may aid, either by their con- 
traction or by being already overstretched, in limit- 
ing motion or change of position in certain directions. 
The head of the bone takes up a new position at some 
distance from its normal one and there establishes a 
new centre of motion for the limb ; consequently the ligaments on the side 
opposite that toward which the head has been displaced are put upon the 
stretch if the attempt is made to move the lower part of the bone in the 
same direction, and, unless torn, fix it at an angle with the other bone to 



Fro. 6. 




Diagram to show the 
action of a ligament in 
limiting the range of mo- 
tion in a dislocation. 



SUBJECTIVE SYMPTOMS. 53 

which they are attached. (Fig. 6.) The bone can be moved toward the 
attachment of the untorn ligament but not further away from it. In 
dislocation of the hip this fixation is very marked because of the angle 
which the neck of the femur makes with the shaft ; when the head of 
the femur is displaced backward the strong Y-ligament which covers the 
front of the joint opposes extension, abduction, and rotation outward of 
the limb, flexion alone being comparatively free ; in dislocation inward or 
downward of the shoulder the limitation of adduction is the most marked 
feature of this kind. 

Since the limitation of motion has its principal cause in the non- 
muscular structures, it cannot be entirely removed by anaesthesia, but 
such additional limitation as may be due to contraction of the muscles 
excited by the fear of pain can be thus removed, and whenever the fixity 
of a limb is used as an element in making the diagnosis, the part taken 
by the muscles in its production should be determined. The diagnostic 
formula given by some authors, that abnormal fixation is characteristic of 
dislocations, and abnormal mobility of fractures, is a partial statement 
that may be misleading, for in fracture, or even in contusion, near a joint 
complete fixation may be effected by the muscles, and in dislocation with 
extensive laceration of the capsule and ligaments the range of motion may 
be very wide. 

The comparison of the mobility of fracture with the immobility of dis- 
location is especially misleading if employed as a means of differential 
diagnosis, for the only fractures that can enter into this question are 
those near a joint, and in such the immobility is often as marked as in 
dislocation, because of the pain and the resistance of the muscles excited 
thereby ; and if anaesthesia is employed to overcome this difficulty it also 
makes other signs appreciable which are more positive and valuable than 
loss of mobility. 

A therapeutical fact that may often be of importance is to be deduced 
from the fact that the dislocation must, in most cases, have taken place 
when the limb was in one of the positions in which, while still dislocated, it 
is shortened — that is, one in which the distance from its normal opposing 
articular surface to its lower end is less than that between the correspond- 
ing points of the opposite limb ; by replacing the limb in the position it 
occupied when the dislocation took place, the first step in reduction, that 
of bringing the head of the bone opposite the rent in the capsule through 
which it has escaped, is taken. 

Crepitation. — A sound or sensation somewhat resembling the crepita- 
tion of a fracture is occasionally perceived while a dislocated limb is being 
handled. It may be the real crepitation of a fracture accompanying the 
dislocation, or merely the grating of the head of the bone against the edge 
of the periosteum of the other, or against a fibrous band, or even (it is 
said) against a blood-clot. 

Subjective Symptoms. 

Pain. — The occurrence of the dislocation is immediately followed by 
sharp pain in the region of the joint, which may gradually diminish or 
may continue for some time with unabated severity. In the former case 



54 SYMPTOMS AND DIAGNOSIS. 

it is presumably due in great part to the laceration and bruising of the 
tissues ; in the latter to the tension of those parts that have not yielded 
to the strain. In the former case the pain is not materially relieved by 
reduction ; in the latter it immediately disappears when the bone is 
restored to its place. In addition to this pain about the joint, there may 
also be tingling or numbness through the limb in consequence of pressure 
upon the larger nerve trunks. 

Loss of Function. — Inability to use the limb is ordinarily complete, 
and is due partly to the fixation created by the changed relations of the 
bones and partly by the pain which movement causes. There is nothing 
characteristic in this symptom, since it is present also after fracture, and 
even after a severe contusion. Furthermore, it is sometimes absent, or 
present in so slight a degree that the patient continues to use the limb, 
conscious only of some slight pain and of a certain inconvenience or lack 
of freedom in its use. Sedillot 1 reported that in three of the five cases of 
dislocation of the hip into the obturator foramen observed by him, the 
patients were able to walk with but little pain and a limp. One of them 
sought treatment only after a fortnight had elapsed, and then only because 
he noticed that the injured limb was abducted and could not be brought 
straight. 

The history of the case includes the character of the violence, the 
position of the limb at the moment of the accident, possibly the percep- 
tion by the patient at that moment of a sound, of the sensation of 
displacement, and the history of any previous injury to or disease of the 
part or of the opposite limb so far as it may affect its use for the purpose 
of comparison. It is well to obtain this history before proceeding to the 
direct examination of the limb. 

There can be no uncertainty as to the main fact if the relations to each 
other of the articular ends can be made out, and the surgeon should not 
rest content with less than this when it can possibly be attained. In 
every doubtful case an anaesthetic should be employed, and among the 
doubtful cases are those in which there is the possible coexistence of a 
fracture either of a portion of the articular surface or of the entire 
breadth of the bone near the joint. The latter form of fracture is itself 
the one with which a dislocation is most frequently confounded ; either 
may be mistaken for the other ; and in any such case every effort should 
be made to determine the exact positions occupied by the ends of the 
bones. When fracture and dislocation coexist, as fracture of the surgical 
neck with dislocation of the head of the humerus, there is no other 
way positively to recognize the dislocation. 

In dislocations complicated by fracture of portions of the articular 
surface or of tuberosities to which muscles are attached, as fracture of 
the rim of the cotyloid or glenoid cavity or of the greater tuberosity of 
the humerus, or of the coronoid process of the ulna, the coexistence of 
the fracture is usually incapable of demonstration and can only be sus- 
pected because of the facility with which the dislocation recurs after 
reduction. 

Such complications as injury of a main bloodvessel or nerve will be 

1 Sedillot: Comptes rendus de l'Acad. des Sciences, Feb. 1861, p. 279. 



SUBJECTIVE SYMPTOMS. 55 

readily recognized by attention to the characteristic symptoms to which 
they give rise. 

A late result of fracture through the tuberosities of the humerus, 
which closely resembles an unreduced dislocation, has been described else- 
where. (Fractures, p. 359.) 

Finally, it should be remembered that the most experienced and careful 
surgeons have sometimes remained in doubt, or have denied the existence 
of a dislocation which the subsequent course of the case has shown to 
have been present, and the charity which the critic may himself so soon 
need should be cordially extended to others. 



CHAPTEE VI. 

COURSE AND PROGNOSIS. 

If the dislocation is promptly reduced and no complications are present, 
the course is simple and the prognosis favorable. The swelling and pain 
subside, and the patient is soon able again to use the limb, although usually 
with some limitation of the range of motion and pain when these limits 
are reached. This slight disability may persist for weeks, or even months, 
especially in those who are constitutionally prone to arthritic complica- 
tions. I have known a robust, thoroughly healthy man, to dislocate his 
shoulder, the dislocation being so slight that it was immediately reduced by 
accidental traction on the arm, and he was able to use the limb without 
a day's intermission ; and yet, three months after the accident, and although 
there was no paralysis, he was unable to lift the elbow in abduction to the 
level of the shoulder, and could not carry his hand to his hip-pocket without 
causing considerable pain. 

If the inflammatory reaction is more severe, the pain and swelling are 
greater and more prolonged, and the limitation of movement may become 
permanent through the formation of adhesions, or the condensation and 
thickening of the periarticular soft parts. It is very exceptional for this 
process to go on to suppuration. 

If the disarticulation is compound, it may follow either one of two 
courses ; either it is transformed into a simple one by the prompt union 
of the wound, or suppuration ensues, and the patient is exposed to all the 
accidents of a deep suppurating wound, rendered all the more extensive by 
its continuity with the interior of the joint. In the latter case the result 
is certain to be marked by much functional disability, perhaps by total 
loss of mobility in the joint. 

Other complications add to the otherwise uneventful course of a simple 
dislocation the features peculiar to themselves ; thus, injury to a nerve 
may be followed by temporary or permanent paralysis of the muscles or 
loss of sensation in the region supplied by it, or by a long train of symp- 
toms indicating an ascending neuritis. Illustrative cases have been 
quoted in Chapter III. And injury to a main artery may be followed 
by gangrene of the limb, or by the formation of a traumatic or encysted 
aneurism. The coexistence of a fracture of the neck of the bone creates 
a condition which for a time predominates over the dislocation ; if the 
latter is promptly reduced the case follows essentially the course of a frac- 
ture ; if it cannot be at once reduced the course at first is still in the main 
that of a fracture, and subsequently that of an old dislocation. 

The fracture of a portion of the articular edge, or of an apophysis, is 
habitually followed by no symptoms peculiar to itself, except in some cases 
a marked tendency to recurrence of the dislocation after its reduction, 
and this tendency may persist throughout life. 



COURSE AND PROGNOSIS. 57 

Excluding these complications, the prognosis in a simple dislocation of 
a limb, quoad vitam, is eminently favorable ; the prognosis with regard 
to the restoration of form and functions depends upon the reducibleness 
of the dislocation, and this is affected by the character of the joint and 
of the injun-, by complications, and by the time that has elapsed since 
the injury was received. 

The principal obstacle to the reduction of a dislocation commonly lies 
in the tension of the untorn portion of the capsule and ligaments, and 
the avoidance of this obstacle is the key to treatment; but special diffi- 
culties may arise from peculiarities in the form of the bones that consti- 
tute the joint, and in the relations of the displaced bone to the capsule 
and to various muscles and tendons. Thus, bony prominences may 
become interlocked, as when in backward dislocation of the elbow the 
coronoid process is lodged in the olecranon fossa, or the end of the bone 
may be embraced between two tendons, as in dislocation of the thumb. 
This latter cause has been suggested in explanation of the difficulty found 
in many cases of backward dislocation of the hip, the head of the bone 
having passed between the tendons of the pyriformis and obturator inter- 
nus ; but examination after death in some of these cases has shown that 
this obstacle was far more apparent than real, and that the head of the 
bone could be readily disengaged from its position between the muscles by 
flexion of the limb. It is probable that this theory, which at one time 
had great vogue and seemed to be supported by anatomical observations, 
is quite erroneous, and that the real reason of the inability to reduce the 
dislocations was that traction alone was employed, and in a faulty direc- 
tion. 

On the other hand, the capsule may slip in between the head of the 
bone and the cavity it has left, and create an obstacle (by its interposition) 
that cannot be removed by manipulation or traction of the limb. The 
cases in which this happens are those in which the capsule is freely torn 
at or near its attachment to the humerus or femur, and in which the head 
of the bone is displaced entirely to the outside of the capsule. Experi- 
ments upon the cadaver (Busch, in Arch, fiir klinische Chirurgie, vol. 
4, p. 1, and Gelle, in Arch. Generates de Medecine, 1861, I.) have 
demonstrated this obstacle, and it has also been encountered in practice. 
A case reported by Hilton 1 is quoted above in Chapter IV., and repre- 
sented in Fig. 4. 

The greater the length of time since the occurrence of the dislocation, 
the greater will be the difficulty of reduction ; and after the lapse of a 
certain length of time, which is different in different cases, reduction 
becomes impossible. The cause of this difficulty lies in the contraction 
and condensation of the soft parts, the establishment of adhesions, and 
the changes effected in the articular surfaces. The inflammatory process 
excited by the traumatism leads to the production of new connective 
tissue in the lacerated parts, which, by its contraction, forms new fibrous 
bonds between the bones and permanently shortens those muscles that 
have been relaxed by the approximation of their points of origin and 
insertion. The edges of the torn capsule contract new adhesions, and 

1 Hilton : Guy's Hosp. Eep., 1847, vol. 5, p. 93. 



53 COURSE AND PROGNOSIS. 

the displaced bone thus becomes so firmly fixed in its new position that 
its return to its original position can be effected only by the employment 
of a force as great as, or even greater, than that which originally displaced 
it, and would be accompanied by more serious and extensive lacerations. 
Moreover, the coincident changes that take place in the articular surface 
and the cavity from which it has been displaced make them unfit to resume 
their functions, so that even if the dislocation could be reduced the joint 
would not thereby be restored. The muscles themselves, through long 
disuse, may in great part lose their contractility, and become transformed 
into inextensible cords composed mainly of fibrous tissue, with a few inter- 
spersed degenerated muscular fibres. 

The period at which a dislocation is to be deemed unfit for reduction 
cannot be positively stated; it varies with different joints and different 
cases. Speaking generally, it is about two months, but it is not prudent 
to assume that any dislocation which has remained unreduced for a shorter 
period than two months is reducible, or that every one that is older is, 
therefore, irreducible ; for in the former case we may be led to apply an 
amount of force that will prove disastrous, and in the latter disabilities 
that are amenable to treatment may be left unrelieved. A better guide 
is to be found in an examination directed to ascertaining the changes 
produced in the parts by the original injury or the disuse, and in careful, 
judicious attempts to make reduction. The object of these attempts 
should not be to reduce the dislocation at any cost, but to reduce it only 
if the reduction can be accomplished by moderate force and without grave 
lacerations. And, indeed, I am inclined to believe that in a doubtful 
case it would be better to expose the bone by incision, and divide the 
obstructing tissues with the knife, rather than blindly to rupture them by 
the application of a force whose action cannot be intelligently directed, 
and whose efforts cannot be certainly foreseen and controlled. Subcu- 
taneous division of the bands has been done in a few cases, and with suc- 
cess ; the objections to the method arise from uncertainty of the exact 
nature of what needs to be done, and of what the knife is doing. Anti- 
septic treatment makes an open wound almost as safe as a subcutaneous 
one, and enables the surgeon safely to explore the field of operation, 
detect the obstruction, and remove it. 

Encouragement to attempt reduction even when the dislocation has 
remained unreduced for a period much longer than that of two months 
above mentioned, is furnished by not a few recorded cases in which it 
has been completely successful ; instances will be given in the following 
chapter. 



CHAPTER VII. 

TREATMENT. 

As a rule, to which there can be very few exceptions, reduction of a 
dislocation should be attempted at the earliest opportunity. The possible 
exceptions are cases in which the inflammatory reaction is already very 
great, and in which it may be anticipated that the additional violence 
inflicted during reduction may be sufficient to provoke a suppuration 
which might otherwise be avoided. But even in such cases it would be 
well to make gentle efforts to reduce under ether, and to postpone the 
reduction only if these efforts proved unavailing. In another class of 
cases, dislocations associated with fracture of the shaft near the dislocated 
end, immediate reduction may prove impossible because of the surgeon's 
inability efficiently to act upon the articular fragment, and then he must 
postpone the attempt until after the fracture shall have united. 

Spontaneous reduction is the term applied to that which takes place 
without the intentional intervention of any external force. It may take 
place while the patient is asleep, through the action of the attached 
muscles or through some chance violence, or by a fall or a sudden move- 
ment. In some of the reported cases, the patient not having been exam- 
ined by a surgeon previous to the reduction, it may be doubted whether 
a dislocation was actually present, and in others there appears to have 
been only a subluxation, or the dislocation was one that had frequently 
recurred, but in others it is certain that the dislocation existed and was 
complete. 

Kronlein 1 received at the Berlin Poliklinic a patient with bilateral dis- 
location of the lower jaw ; reduction was postponed until after the other 
patients had been attended to, and then the bone was found restored to 
its place. Malgaigne 2 reports a similar case in his own hospital service ; 
the interne tried in vain to reduce it, and spontaneous reduction took 
place during the night. 

Velpeau 3 saw two cases of spontaneous reduction of dislocation of the 
shoulder. In the first the patient fell as she left her bed to go to the operat- 
ing-room, striking upon the elbow of the injured side. In the second, in 
which the dislocation was ten days. old and the head of the humerus was 
displaced far under the clavicle, the patient was put in bed with his fore- 
arm supported by a bandage ; during the night spontaneous reduction 
took place without removal of the bandage or any effort on the part of 
the patient ; he said he had suffered during part of the night and had 
felt the shoulder crack. 

In a case that subsequently came under my care the patient, himself a 

1 Kronlein : Deutsche Chirurgie, Lief. 26, p. 54. 

2 Malgaigne : Luxations, p. 32. 3 Quoted by Malgaigne. 



60 TREATMENT. 

physician, was thrown from a wagon, striking upon and dislocating his 
right shoulder. While continuing his journey and suffering severely, he 
attempted to get a flask of brandy from his valise that lay upon the seat 
beside him ; with the hand of the injured arm he grasped the handle of 
the valise to steady it while he opened the lock with the other ; a sudden 
jolt threw the valise from the seat, and by the involuntary effort to arrest 
its fall its weight was brought upon the injured arm and the bone slipped 
back into place with a distinct snap and immediate relief of the pain. 

Malgaigne gives several examples of spontaneous reduction of dislocation 
of the hip. In one, a dislocation downward and forward, the operation 
for reduction was postponed and the patient placed in bed ; during the 
night he sought to turn upon his side and raised the limb with his hands, 
the pain caused him suddenly to loose his hold, a snap was heard, the 
pain ceased, and the dislocation was found to be reduced. In another, 
many fruitless attempts had been made to reduce a dislocation inward, 
and the case had been abandoned. One day the patient was getting into 
a wagon and had placed the sound foot upon the step, while raising the 
other he heard a dull sound, and the bone was found to be in place. 

In another 1 a young man fell from a height with his legs apart, and at 
once suffered great pain in the upper part of the thigh and felt a hard 
lump there. Without changing his position he pressed upon this lump, 
and it disappeared with a distinct sound. It was thought to have been 
a dislocation of the femur downward and forward. 

A case observed by Cornish and quoted by Sir Astley Cooper 2 is very 
remarkable because of the length of time, five years, between the occur- 
rence and the reduction of the dislocation. It was a dislocation of the 
hip upon the dorsum ; the patient went on crutches for five years, and 
then, while making a voyage, was thrown from his berth to the deck, and 
the dislocation was reduced with a loud snap ; he was afterward able to 
walk easily and without a limp. Cornish, who fully appreciated the 
remarkable character of the case, lived in the same town with the patient, 
and knew and examined him both before and after the reduction. 

In other cases spontaneous reduction, without the aid of external force, 
has followed shortly after attempts to reduce which have been unsuccessful 
but which may be thought to have made spontaneous reduction possible by 
rupture of adhesions, or laceration of the tissues, or fatigue of the muscles. 
This variety was termed consecutive reduction by Leveille, and the term 
was adopted by Malgaigne, who applies it both to cases in which spon- 
taneous reduction takes place after complete failure of the efforts to reduce 
and also to those in which an incomplete reduction spontaneously becomes 
complete or is gradually made complete by the prolonged action of some 
force applied by the surgeon — such as pressure. The following examples 
are quoted from Malgaigne : 

A man fifty-four years old came to Palletta with a dislocation of the 
shoulder a week old ; many fruitless attempts to reduce had been made, 
and the elbow and forearm were prodigiously swollen. After some days 
of preparatory treatment Palletta tried to reduce with Freke's machine 

1 Gazette des Hopitaux, 1846, p. 60. 

2 Cooper: Dislocations and Fractures, Am. ed., p. 81. 



TREATMENT. 61 

and failed ; the attempt was repeated four days later, and this time the 
head of the bone shifted its place somewhat, with the accompaniment of 
a cracking sound ; the patient was replaced in bed, and the arm supported 
in a sling. Two days afterward the bone was found apparently in place 
and the movements of the joint had become much more free, but still 
something was lacking in the form of the region, and it was not until 
after three or four days more that the reduction became complete. 

A similar case came under Malgaigne's own observation : a very marked 
intra-coracoid dislocation of the humerus which had resisted twenty-one 
attempts to reduce it before the patient came to Malgaigne. The swell- 
ing being enormous, he instituted a preparatory treatment and then 
applied the pulleys, but the pain was so great that he was obliged to 
desist. A week later he tried again, and while engaged in the effort he 
drank by mistake an emetic prepared for the patient, and was thereby 
again obliged to abandon the attempt after having brought the head of 
the bone somewhat nearer the glenoid cavity. The elbow was supported 
in a sling, and the shoulder covered with poultices. The next day the 
shoulder was found to have regained, in great part, its natural form, and 
during the following days the reduction became complete. 

Other cases involving the hip are mentioned by different authors, but 
without exact references. 

The obstacles to the reduction of recent uncomplicated dislocations 
arise from inflammatory swelling of the soft parts, muscular contraction 
excited by pain or the fear of pain, the inextensibility of untorn portions 
of the capsule or ligaments of the joint, the interposition of portions of 
the capsule between the head of the bone and its cavity, and the size and 
position of the rent in the capsule. All of these are not present in every 
case, and they vary in importance. For a long time the muscles were 
deemed the most important, but observations and experiments upon the 
cadaver carried on at about the same time by several different persons — 
Gunn 1 in 1851, Gelle 2 and Bigelow 3 in 1861, Streubel 4 in 1862, and 
Busch 5 in 1863 — fixed the attention of surgeons upon the relations 
between the bone and the capsule, showed the nature and importance of 
the opposition commonly offered by the latter, and established the basis 
of treatment by systematic manipulation. 

An account has already been given of the part played by the untorn 
portion of the capsule in determining the position assumed by the limb, a 
part so important that in "regular" dislocations (the term given by 
Prof. Bigelow to those in which the rent in the capsule is only partial 
and occupies a certain definite place in it) the muscles surrounding the 
joint may all be divided without thereby modifying the position of the 
limb or increasing its range of motion. At the hip the portion which 
remains untorn in all the typical forms is the anterior portion or Y- 
ligament ; at the shoulder it is the thicker anterior portion forming the 
so-called coraco-humeral ligament. It is more correct to speak of the 

1 Gunn: Peninsular Journal of Med., July, 1855, p. 27. 

2 Gelle: Archives generates de Med., April and Mav, 1861. 

3 Bigelow: The Hip. 

4 Streubel: Vierteljahreschrift fur prakt. Heilkiinde, 1862, ii. p. 59. 

5 Busch: Arch, fur klin. Chirurgie, 1863, p. 1. 




62 TREATMENT. 

obstacle offered to reduction by this untorn portion of the capsule as an 
obstacle not to reduction in general, but only to reduction by certain 
methods, for when properly managed it offers no opposition, and may 

possibly even be of assistance. It may be 
Fig. 7.' compared to the link of a sleeve-button, 

which in some positions absolutely prevents 
the button from passing back through the 
button-hole, while in other positions the 
passage is easy. Thus, if the head of the 
bone is displaced, for example, to the right 
and lodged behind a projecting portion of 
the rim of the articulation, the ligament 
(Fig. 7, A) is tense, and traction in any 
direction which tends to separate its points 
of attachment is effectually opposed by it; 
but if these points are brought nearer to- 

Diagram to illustrate the action Of ,-, i ,-, -i «, £ . ,i -, 

an untorn ligament or portion of cap- g ether h J ™OVing the shaft of the bone in 

suie in opposing reduction. the direction indicated by the arrow, the 

ligament is thereby relaxed and its opposi- 
tion to the movement of the head of the bone toward its cavity annulled. 
The position of the untorn portion of the capsule or ligament must be 
inferred from the posture of the limb and the directions in which motion 
is strongly opposed. 

In "irregular" dislocations, those in which a characteristic attitude is 
not taken by the limb and in which the mobility is marked, these differ- 
ences are due to extensive rupture of the capsule ; and this, by removing 
the restraint imposed in other cases by the untorn portion of the capsule, 
makes reduction remarkably easy without much attention to the position 
in which the limb is held during the attempt. 

In addition to this opposition to movement or traction in certain direc- 
tions, the capsule may offer other obstacles arising from the form and 
position of its rent and from its own possible interposition between the 
head of the bone and the cavity in which the latter is to be replaced. 
The tearing of the capsule is caused by the pressure of the head upon it, 
consequently the rent is on the side toward which the head is displaced, 
and it may be longitudinal or transverse at either attachment, or present 
a combination of the two forms. In order that either of these obstacles 
should be present, it is necessary that the head of the bone should have 
passed entirely through the rent — that, in other words, its displacement 
should be marked. As the rent, under these circumstances, is large 
enough to allow the head to pass out through it, it is large enough to 
allow it to be brought back through it if it is not made too narrow and 
its sides too tense by traction upon them. The effect of traction to 
narrow the opening can be demonstrated on the cadaver (Streubel, loc. cit., 
p. 70) by producing a subcoracoid dislocation of the humerus or an 
obturator or ischiatic dislocation of the femur, exposing the region by 
removal of the muscles, and then making traction in the extended posi- 
tion. As the capsule is made tense the sides of the longitudinal part of 
the rent are drawn together, and their lateral separation, which alone 
would allow the globular head of the bone to pass back, is prevented. 



TREATMENT. 63 

The narrowness of the gap is at once relieved by changing the position 
of the limb in such manner as to bring the points of attachment of the 
capsule nearer together, and the transverse portion of the rent can be 
lengthened by rotating the limb. 

Interposition of the capsule between the head and its cavity may exist 
whenever a secondary displacement has succeeded the primary one and 
the head has moved from the point at which it escaped along the outside 
of the capsule, but unless the capsule has been so torn as to form a flap 
adherent by its base to the edge of the articular cavity, this interposition 
can be readily avoided by moving the head of the bone back to the posi- 
tion of primary displacement. If, on the other hand, such a flap has. 
formed and has fallen between the articular surfaces (as in Fig 4. p. 47). 
there is no means, short of an operation that directly exposes it, of cer- 
tainly getting it out of the way : it is attached to only one bone, and 
consequently cannot be acted upon by moving the other or changing the 
relations to each other of the two. 

Another obstacle, similar in character to that offered by a narrow rent 
in the capsule, may be occasioned in dislocations backward of the thumb 
upon the metacarpal bone by the passage of the head of the latter between 
the flexor tendons that are attached to the base of the phalanx ; the 
tendons, after separating to allow the head of the bone to pass between 
them, embrace the narrower neck tightly, because they are overstretched, 
and the attempt to reduce by drawing the phalanx downward only makes 
them more tense. The difficulty can sometimes be overcome by un- 
buttoning the head, as it were, by pressing the phalanx to one side and 
then, by a movement of rotation and circumduction, slipping the tendon 
of that side past the head of the bone. 

Swelling of the soft parts interferes with reduction by increasing the 
bulk of the limb within the fascia and thereby mechanically opposing 
changes in position. If it is very great it may be proper to defer reduc- 
tion and combat it by rest, cooling lotions, and pressure ; it will usually 
subside so promptly that the loss of time thus incurred will not add 
appreciably to the difficulty of reduction when it is undertaken. 

Contraction of the muscles, provoked by the traumatism or the fear 
of pain, opposes reduction by preventing the preliminary changes of 
position and neutralizing to a greater or less extent the traction that is 
made upon the limb. It may be overcome by gentle and long-continued 
traction, or fofciblv, or bv anaesthesia, or it mav be avoided by taking 
the patient unawares or distracting his attention at the critical moment. 

The methods formerly employed of weakening the patient by emetics 
or bloodletting, or stupefying him with alcohol or opium, have now been 
entirely abandoned. Other methods that have been recommended — the 
passage of the constant galvanic current through the muscles (Remak) 
and compression of the main artery (Rist) — have been entirely neglected 
because of the superiority of anaesthesia by ether or chloroform. 

Anaesthesia is far from being needed in all cases, and as there are 
certain discomforts and even dangers in its use an attempt to reduce with- 
out its aid should usually be made. In ]S"ew York, and, I think, in most 
of the large cities of the United States, ether is habitually used in 
preference to chloroform, and although chloroform is still used in Europe. 



64 TREATMENT. 

the greater safety of ether is almost universally admitted. The collected 
cases of death under chloroform apparently prove the correctness of an 
opinion quite generally held that its use in dislocations is especially 
dangerous, although no satisfactory explanation of the fact has yet been 
given. Of 101 fatal cases collected by Kappeler 1 between 1865 and 
1876, 11 were dislocations, 20 amputations, and 1 1 operations upon the 
eyes; of 134 cases collected by Marchand 2 17 were dislocations, and 15 
extractions of teeth. It is not always necessary to push the use of ether 
to complete ansesthetization, for the relaxation is sometimes sufficient 
during the stage of primary anaesthesia, if care is taken not to excite the 
.patient unduly. Gentle traction may be made upon the limb as the 
anaesthetization is begun, and its direction gradually changed or merged 
into the desired manoeuvres as the muscles are felt to yield. 

Since the nature of the obstacles to reduction has been more correctly 
understood the methods by forcible traction have been so far superseded 
by the methods of manipulation that they now possess only an historical 
interest. They consisted essentially in extension (traction), usually in 
the line of the dislocated limb, and counter-extension to bring the head 
of the bone down to the level of its cavity, followed then by measures of 
" coaptation " to force it into place. The traction was made through 
bands attached to the lower segment of the limb, and the force was 
exerted either directly by the hands of several assistants or indirectly 
through pulleys or screws. The amount of force sometimes exerted by 
these means can be inferred from the disastrous and even fatal conse- 
quences that occasionally ensued, including rupture not only of muscles 
and ligaments but also of the principal nerves and bloodvessels, and even 
complete avulsion of the limb. Suppuration of the joint, followed by 
the death of the patient, an accident which is now very rare, was formerly 
quite common, and in very many of the cases which recovered the record 
plainly shows the violence of the reaction and how narrowly the patients 
escaped with their lives. The occasion for the exertion of so much force 
arose from the faulty direction in which it was frequently applied, one in 
which the head of the bone could not be brought down to the level of 
the cavity without preliminary rupture of the opposing soft parts. The 
laceration caused by the dislocation was increased by the treatment, in 
order to enable the bone to follow a course which the ligaments, if 
untorn, would effectually bar. The method was directed against an 
obstacle, the resistance of the muscles, which was only one, and not the 
chief, of those w T hich opposed reduction, and was pursued in ignorance of 
the principal one ; violence was used to overcome an obstacle which cor- 
rect anatomical knowledge would have enabled the surgeon to avoid. 

It must not be understood that this extreme violence was exerted in 
every case. In many the traction was made in a proper direction, or at 
least in one in which the already existing laceration of the capsule 
allowed the bone to be moved ; hence, many dislocations were reduced 
with comparative facility, especially those of the shoulder and those of 

1 Kronlein : Loc. cit., p. 66 

2 Marchand : Des accidents qui peuvent .eompliquer la redaction des luxations 
traumatiques, 1875, p. 134. 



TREATMENT. 65 

the hip in which consecutive displacement had not materially changed 
the posture of the limb, and in such cases traction was a proper means 
to overcome the opposition of the muscles. It was in such cases, too, 
that the methods of continuous moderate traction by India-rubber, weight 
.and pulley, and suspension by the limb (" pendel-methode ") were 
successfully employed, and will still be when it is desired to avoid recourse 
to the aid of anaesthesia. 

As long ago as in the time of Hippocrates (fifth century B. C.) it had 
been known that some dislocations of the hip could be readily reduced by 
manipulation without the aid of violent traction, 1 and, as already men- 
tioned, Galen (second century A. D.) had pointed out that the head of the 
bone should be returned to its cavity along the route by which it had 
escaped, yet these suggestions remained unknown or unheeded and the 
practice of surgery, as regards dislocations, appears to have been not 
only ineffectual to relieve in a large proportion of cases, but also charac- 
terized by dense ignorance of their pathology and by the crudest notions 
of the mechanical effects of the means by which their reduction was 
attempted. Thus, among the methods in vogue, according to Petit, 
for the reduction of dislocations of the shoulder, at the beginning of the 
eighteenth century, were those of the door or ladder, the bar, and the ambi. 
In the former the patient was made to stand upon a stool, and the dislo- 
cated arm was brought over the top of a door or a rung of a ladder so 
that the latter occupied the axilla ; then, while an assistant grasped the 
wrist and drew it directly downward, the stool was taken away and the 
patient left suspended until the surgeon pronounced the dislocation 
reduced or abandoned the attempt. In other cases the patient was lifted 
from the ground upon a bar supported on the shoulders of two men and 
passing under his axilla ; or a large, strong man seized the patient's wrist, 
placed his own shoulder under the axilla, and then suddenly straightening 
himself raised the patient from the ground, at the same time drawing the 
arm down forcibly in front of himself. The method of the heel, so 
strongly recommended by Sir Astley Cooper, w T as also employed by them, 
and sometimes with success. 

The ambi, an instrument invented by Hippocrates, was also in favor; 
it consisted of two oblong pieces of wood joined together at the end by a 
liinge, of which one was placed vertically against the side of the patient, 
the hinge pressed well into the axilla, and the other under the arm in the 
position of horizontal abduction. The arm was then firmly secured to 
the latter piece and forcibly depressed. 

As the defective mode of action of these methods became more o-ener- 

1 Prof. Bigelow (The Hip, p. 28) gives the following translation of the passage : 
-" In some the thigh is reduced without preparation, with slight extension, directed 
by the hand, and with slight movement; and in some the reduction is effected by 
bending the limb at the joint with gentle shaking." This translation of the last 
word, which has been interpreted by others as meaning making rotation, is made on 
the authority of Prof. Sophocles, who says: "Your question has reference to the 
meaning of the word Kb/K?uacg, the formation of which is as follows : /dryic^og, wag-tail, 
a well-known bird in Greece. . . . Kiyk^'i^a, to wag (in the original sense of the 
-term), as the bird aforesaid wags its tail, niyrfdatg and KiyK/avuog , a. wagging : shak- 
ing rapidly within narrow limits ; gentle shaking. The words cireumactio and rota- 
tion are out of the question, . . . unless rotation be used in a special sense." 

5 



00 TREATMENT. 

ally recognized, traction by the hands of assistants or by pulleys or by 
other apparatus was substituted, but although this was an improvement 
upon its barbarous predecessors it was still employed blindly, and evi- 
dently was often ineffectual. There are indications in the older writings 
that the practice was not so wholly bad as the teaching, that here and 
there men were found who not only appreciated the importance of the 
direction in which traction should be made, but even occasionally reduced 
dislocations by manipulation alone, but the writer who seems to have 
been the first to recognize the importance of the principle enunciated so 
long before by Galen of bringing back the head of the bone by the route 
along which it had escaped, and of the position to be given to the limb 
during the attempt, was Jean Louis Petit. His Traite des maladies des 
Os was published in 1705 ; a second edition followed in 1723, and a third 
in 1741. He clearly pointed out the mechanical defects of the methods 
then in use, and the necessity of first bringing the head of the bone 
back to the opening in the capsule through which it had escaped before 
attempting to replace it in its cavity ; and he drew from observation of 
the different degrees of tension of the different muscles inferences as to 
the position in which the limb should be placed and the direction in 
which traction should be made, which were of great practical value, 
although based upon notions concerning the obstacles that opposed reduc- 
tion which were incomplete in that they took no account of the untorn 
ligaments and capsule. Thus, in dislocation inward or downward of the 
shoulder he abducted the elbow widely, and in those of the thigh back- 
ward he flexed the limb and then changed its position when the head of 
the bone had been brought down to the proper level. 1 

Recognizing the necessity of making counter-extension upon the 
scapula instead of the thorax in reducing dislocations of the shoulder, he 
invented a machine consisting of two parts : one, to make extension, was 
composed of two long parallel bars bearing a small windlass near one 
end ; the other, for counter-extension, was a strip of stout canvas covered 
with soft leather, split longitudinally for some distance in the centre, and 
furnished with a pocket at each end. The arm was passed through this 
central slit to the shoulder, and the ends of the parallel bars fitted into 
the pockets. The limb rested between the bars. Extension was made 
by a cord fastened to the arm above the elbow and carried around the 
windlass ; counter-extension was made by the canvas against the acro- 
mion and anterior border of the scapula. The machine used for the hip 
was similar. 

Petit, in thus departing from the practice of his predecessors and con- 
temporaries, had entered upon the right path ; he erred in not following 
it far enough, and his error arose from a too limited notion of the 
obstacles to be overcome. He noticed that some muscles were tense and 

1 Si la cuisse est luxee en haut et en dedans, c'est-a-dire sur Pos pubis, le bout 
inferieur de la machine [which made traction and extended beyond the knee] doit 
etre porte un peu en arriere, quand on commence l'extension ; et il faut le raprocher 
en devant, quand on croit que l'extension est suffisante. Au contraire, si la cuisse 
est luxee en hautet en dehors, il faudra, en commencant l'extension, porter le bout 
de la machine en devant, et le repousser en arriere, lorsque les muscles paroitront 
suffisament allonges." Petit, loc. cit., p. 201. 



TREATMENT. 67 

others were relaxed, and he sought to place the limb in a posture that 
would remove these differences, while at the same time traction made in 
the direction of its long axis would bring the head of the bone to the 
point at which it had escaped from its cavity. His improvements were 
appreciated, and his practice was essentially followed by most surgeons 
until within the last few years. Yet one of his early successors, 
Pouteau, 1 in a paper embodying ideas conceived in 1749 (see loc. cit., vol. 
2, p. 237), pointed out the defects of the method as applied to disloca- 
tions of the hip, and supported his own arguments and modifications by 
the record of several successes. He says (p. 222) that in the first case 
of dislocation of the hip upward and outward (on the dorsum of the 
ilium) which he was called upon to treat he employed Petit' s method 
and failed. That is, he made extension with the limb somewhat flexed, 
counter-extension being furnished by the canvas band of Petit's machine, 
the centre of which pressed against the tuberosity of the ischium, while 
its ends lay, one in front of the abdomen, the other behind the buttock. 
The reflections excited by this failure led him, when the next case pre- 
sented itself, a few months later, to make traction with the thigh flexed 
at a right angle, and the effort was promptly successful. He placed the 
patient on his back on the floor, laid the canvas band along the groin, 
with one end between the thighs and the other on the outer side of the 
injured hip, flexed the thigh to a right angle, engaged the ends of the 
bars in the pockets of the counter- extending band, and made traction; 
when he deemed the traction sufficient, he gently rotated the thigh out- 
ward 2 and reduction at once took place. Furthermore, he showed that 
the resistance of the muscles was due to their involuntary contraction 
and was to be more readily and safely overcome by prolonged moderate 
traction than by more violent but briefer efforts. He says (loc. cit., p. 
226) : "I have several times observed that it is easier to temporize than 
immediately to overcome the resistance of these muscles ; so, when the 
extension seems to be sufficient I maintain it at the same point for some 
time and wait for the relaxation which fatigue must bring about. It is 
then only necessary to profit by this moment of inaction to effect the 
reduction." 

Pouteau's practice closely resembled that which represents the appli- 
cation of the principles of the modern method by manipulation, and is 
identical with that of moderate traction upon the flexed limb which is 
now in common use and is, I think, generally preferred to that of pure 
manipulation. He flexed the limb to bring the head of the bone nearer 
the opening in the capsule, made traction to lift it to the level of the 
cotyloid cavity, and then turned it in by outward rotation or abduction, 
or both. He knew even that the traction could sometimes be dispensed 
with and the reduction effected by manipulation alone, and in quoting 
successes thus obtained by Maison-neuve, he predicts that a simpler 

1 Pouteau: CEuvres posthumes, Paris, 1783. Pouteau died in 1775. 

2 "Je tournai sans effort la cuisse du dedans en dehors." That by this he means 
external rotation and not abduction is probable, I think, from his use of a similar 
but more definite phrase in a later description (p. 234) of the reduction of a thyroid 
dislocation, " pendant qu' un aide tournoit le genou de dehors en dedans." Still, 
the two movements were probably associated. 



68 TREATMENT. 

method than his own will be found. The failure of his practice to 
become generalized is probably due to the influence of tradition and of 
the authority of Petit, reinforced as the latter was by the great advance 
he had made over the practice of his predecessors, and perhaps to the 
insufficient publication of Pouteau's views. The paper from which the 
above quotations are made appears to have been written in 1749, but 
there is no evidence that it was published elsewhere than in the posthu- 
mous collection of 1783, which, consisting of disconnected essays upon 
various subjects, probably had only a limited circulation. Whatever the 
cause may have been, the result is beyond question ; surgeons continued 
to reduce dislocations of the hip by traction with the pulleys, the limb 
being only slightly flexed, and by pressure applied at the upper part of 
the thigh to move the head laterally into the cavity. Sir Astley Cooper 
habitually used only extension, followed by rotation of the thigh inivard. 

Prof. Nathan Smith, of New Haven, taught and practised a method 
of reduction by manipulation which was published in 1831 after his 
death, in his Medical and Surgical Memoirs, edited by his son, Nathan 
R. Smith, and this, Prof. Bigelow says, " covers the ground of priority 
of invention." See Chapter XXV., Treatment. 

The next published recognition of the possibility of reducing a dislo- 
cation of the hip by manipulation alone was by Despres, who, in 1835, 
communicated to the Societe Anatomique of Paris 1 "a new method of 
reducing dislocations of the femur" by flexion and rotation outward. 
The only comment it excited at the time, according to the records of the 
society, was the mention a few months later by Pigne of the fact that the 
same method was described by Beach in a Treatise on Medicine, pub- 
lished in New York in 1833, and was there said, on the authority of 
Sweet, the " natural bone-setter," to have been practised by the savages 
of North America. 2 The Despres incident is mainly noteworthy as 
showing how completely the previous suggestions had been forgotten or 
overlooked, even by Pouteau's own countrymen. It is now used by the 
French as a justification for speaking of the method by manipulation (at 
the hip) as the " Methode de Despres." 

In like manner, other surgeons sought to modify the practice as 
regarded the shoulder-joint, by advising that the traction should be made 
in different directions and combined with rotation of the limb. Of these 
the most noteworthy are Mothe and Lacour, since it is with their practice 
that the manipulative methods are generally thought to have begun. 

The earlier manipulative methods were either empirical or based upon 
more or less incorrect notions of the nature of the obstacles to be over- 
come and of the mechanism by which the result was to be obtained, and 
it is only since the pathology of the different dislocations has been better 
understood, with reference especially to the position of the rent in the 
capsule and the influence of the portions which remain untorn, that the 
different procedures embraced under this method have been intelligently 
devised and executed. They differ so widely in their details that only 

1 Despres : Bull, de la Soc. Anatomique, Sept. 1835, p. 4. 

2 Beach, like Sweet, appears to have been an irregular practitioner, and it is 
likely that his assertions, even when known, were not deemed worthy of serious 
consideration. 



TREATMENT. 69 

the most general description can be given here ; they consist in giving 
to the limb successive different positions, by which the head of the bone 
is first brought opposite the opening in the capsule and then into its 
cavity, and by which the opening in the capsule is made to gape widely, 
or is actually enlarged if necessary. For the accomplishment of these 
ends the limb is used as a means of acting upon the capsule so far as it 
remains attached to the bone, and the head of the bone is made to take 
its successive positions by rotation of its shaft, or by using it as a lever 
which finds its fixed point either upon some adjoining prominence of 
bone or in the capsule, or by moving the entire limb in the direction of 
its long axis. Combined with these manipulations it is commonly neces- 
sary to employ a certain amount of traction either to overcome such 
resistance as is offered by the muscles or to lift the limb, as in a backward 
dislocation of the hip when the patient is lying on his back. The latter 
necessity is sometimes obviated by supporting the patient face downward, 
so that the weight of the dependent limb will aid reduction instead of 
opposing it. 

It rests essentially upon an anatomical and pathological basis consisting 
of two parts, the position of the rent in the capsule and the resistance 
of the untorn portion, and depends for its knowledge, in any given case, 
of these two factors mainly upon the position occupied by the limb and 
the limitations of the movements. Resistance of the muscles, when 
present, is overcome by anaesthesia or by traction. 

Such traction as is required is made by the hands of the surgeon or of 
an assistant, or, as above mentioned, by the weight of the dependent 
limb, or by the prolonged action of an elastic band or of a weight 
suspended over a pulley. 

Continuous extension by India-rubber bands w T as practised by Legros 
and Onimus while internes in the Paris hospitals, 1863 to 1866, and 
advocated by them in a paper published in 1868. l They recognized that 
their object, the fatigue of the opposing muscles, could be equally well 
accomplished by weight and pulley or a steel spring, but they give the 
preference to India-rubber because of the ease with which it could be 
used. Their reported cases are dislocations of the shoulder and elbow. 
The method is so simple, so easily practised, so free from pain that it is 
well worthy of trial ; its neglect of late, which has been almost complete, 
is doubtless due in great part to a preference for immediate resort to 
anaesthesia, and to failures due to lack of perseverance, or to faulty 
direction of the traction. 

The method of application in dislocations forward of the shoulder, for 
example, is as follows : A loop is made fast to the lower part of the arm 
by turns of a roller bandage or by strips of adhesive plaster as in Buck's 
extension ; then the patient is seated in a chair, counter-extension pro- 
vided by a band passing around the chest under the axilla and over the 
opposite shoulder and made fast to some neighboring fixed point, the 
elbow gently raised to or nearly to the position of horizontal abduction, 
and extension made in the direction of its long axis by a rubber Cord 

1 Legros and Ominu? : Des tractions continue?, et de leur application en chirurgic. 
Arch. Generales de Med., January, 1868. 



70 TREATMENT. 

passed through the loop attached to the arm and around a fixed point 
established in an appropriate position. The traction should be about 
twenty or twenty-five pounds, and needs to be continued for from fifteen 
to thirty minutes ; under its influence the muscles become relaxed and the 
patient experiences the sensation of great fatigue, the head of the bone 
gradually approaches the glenoid cavity, and either enters it spontane- 
ously or is replaced by the pressure of the surgeon's fingers, or by a 
sudden pull upon the arm. Instead of the rubber, a weight and pulley 
may be conveniently used, and the direction of the traction changed 
when necessary by shifting the position of the pulley. 

Evidence of the success of the effort to reduce is furnished by the 
sound commonly heard on the reentrance of the head of the bone into 
the cavity of the joint, and by the restoration of the normal form of the 
region.' 

When the dislocation is no longer recent — that is, when a sufficient 
period has elapsed for subsidence of the inflammation, and for union of 
the lacerated tissues in their new relations, but while there is reason to 
think that reduction is still possible — manipulation alone will not suffice, 
but resort must be had to other measures, such as more forcible traction 
and rotation, to break up the adhesions, and thus restore to the displaced 
bone the mobility which it possessed when the injury was recent. 

It is always a very difficult question, and one that cannot fail to cause 
the surgeon much anxiety, whether the attempt to reduce should be 
made, and how much force may properly be used in it. The length of 
time that has elapsed is not of itself sufficient to determine the answer to 
this question, for experience has shown the widest differences in this 
respect, some dislocations proving irreducible after two or three weeks, 
while others have been quite readily reduced after the lapse of several 
months. Some help may be got from consideration of the amount of 
inflammatory reaction immediately following the injury, from the position 
and mobility of the head of the bone, and possibly by recognition of the 
condition of the articular cavity ; but, after all, a positive answer can 
only be obtained by making the attempt. It is hardly necessary to add 
that the attempt should be made with the utmost caution, and with 
constant attention to the dangers with which experience has shown it is 
surrounded, especially rupture of large adjoining vessels and nerves, and 
fracture of the bone. As has been already said, the difficulty lies not only 
in the adhesions which fix the bones in their new relations, but also in 
the possible closing of the rent in the capsule, and in the shutting off of 
the articular cavity by the formation of adhesions between its margin 
and the overlying capsule. When these conditions exist, reduction with- 
out a cutting operation is practically impossible. 

The danger is by no means to be measured by the force employed in 
the attempt, for it is dependent also upon the changes undergone by the 
tissues in consequence of the dislocation, and upon their inability to 
accommodate themselves to the changing positions of the limb during 
manipulation. As dislocations of the shoulders are more common than 
all other dislocations taken together, and as rupture of the axillary 
vessels is not only the most dangerous, but also the most frequent acci- 
dent during attempts at reduction ; and as, moreover, a dislocated arm 



TREATMENT. 



71 



may still be a very useful member, it is not surprising that surgeons, 
speaking under the sense of their responsibility as teachers, have often 
uttered strenuous warnings, like this of Hutchinson's, 1 who, after calling 
attention to the chance of accident in elderly patients, adds : " Let me 
beg of you not to allow any impulse of selfish vanity or the desire to 
vaunt an unusual success mislead your judgment into attempting that 
which is not really for your patient's advantage. Let him go elsewhere 
if he likes, and let another possibly obtain the credit of success ; you 
will still be able to reply, with the celebrated general, that, despite the 
fact of victory, you still hold to your former judgment that the battle 
ought not to have been fought." 

The same keen sense of the risk involved was shown by the late Pro- 
fessor Gross, 2 when he said, "I have never had charge of an old or 
neglected dislocation without a strong secret wish that it had fallen into 
other hands, such have, usually, been my disappointment and the anxiety 
.attendant upon my efforts at reduction." 




Jarvis's adjuster. 

When it is sought to reduce a dislocation that is no longer recent, the 
first effort should be to liberate the displaced head by rotation of the 
shaft, with the view of thus breaking up the new adhesions, and then 
traction should be made with pulleys, or with a machine such as Jarvis's 
adjuster (Fig. 8), which consists essentially of two metal rods movable 
upon each other by a rack and pinion, one of which is made fast to the 
distal segment of the limb for extension, while the other makes counter- 
extension above. These instruments, as now made, are furnished with a 



1 Hutchinson : Med. Times and Gazette, 1866, i. p. 304. 

2 Gross's Surgery, sixth edition, vol. i. p. 1117. 



72 TREATMENT. 

dynamometer, which indicates the amount of force that is being exerted r 
and the same indicator may also be used with the pulleys. The machine- 
has the advantage over the pulleys of allowing the position of the limb to 
be changed at will, and the disadvantage that the traction cannot be 
suddenly released. When pulleys are used, this sudden release is 
effected by interposing between them and the limb a specially devised 
catch, constructed like a pair of forceps, by pressure upon the handles of 
which the end is liberated. 

Traction by the hands of several assistants is dangerous, because of 
the difficulty of regulating the force exerted by them, which, by a sudden, 
well combined effort, may become excessive. It seems probable that we 
shall see much less in the future than in the past of these repeated, pro- 
longed, forcible efforts to reduce old fractures, and that surgeons will 
resort instead to arthrotomy to effect reduction, or to excision or fracture 
to improve the position of the limb. All three methods have yielded 
some good results already, at the shoulder, elbow, and hip. 

The antiseptic method has earned the complete and well-founded confi- 
dence of the profession, and it has been abundantly proved. that under its 
protection even the largest joints can be opened with but little risk ; the 
disasters that have followed incisions in cases of articular fractures and. 
dislocations have been usually due, in my opinion, to the selection of an 
unfit time for the operation, one when the injury was still fresh and the 
parts bruised and infiltrated with blood. Against a dangerous reaction 
under such circumstances antiseptics do not afford an adequate security, 
and the surgeon who proposes to open a dislocated joint should, I think, 
wait, if possible, until the reaction following the original traumatism has 
ceased. 

The different operations will be described in connection with the 
special dislocations. 

After-treatment. — After a dislocation has been reduced, there is 
needed, in most cases, only a simple retention bandage to confine the 
limb in an easy position. After a dislocation of the shoulder or elbow, 
the arm is bound to the side, with the forearm flexed and resting across 
the chest ; after a dislocation of the hip nothing is needed but quiet rest 
in bed. In some other cases, dislocation of either end of the clavicle, of 
the head of the radius, or of the shoulder backward under the spine of 
the scapula (Busch and Kronlein), the tendency to recurrence is so great 
that special dressings are required. The joint should be kept quiet, cer- 
tainly any movement that Causes pain should be avoided, and if the 
inflammatory reaction threatens to be severe it must be opposed by the 
application of cold, or uniform gentle pressure if it can be borne. After 
the lapse of a week or two, passive motion within painless limits may be 
made, and the use of the limb gradually resumed. In making this 
passive motion or this use of the limb, those positions must be avoided in 
which the head of the bone would press upon the torn part of the 
capsule, or in which the sides of the rent would be again separated from 
each other. 

If, as sometimes happens, the joint remains stiff, weak, and sensitive, 
but is cold rather than warm, and aches, and perhaps becomes puffy after 
use, it needs massage and rubbing, and to be actively moved, either by 



TKEATMENT. TSt 

the patient or by the physician. Its sensitiveness and immobility under 
such circumstances are due to the prolonged disuse, to retraction and 
loss of pliability in the periarticular tissues, and possibly to the presence 
of adhesions within the cavity itself. Sir James Paget 1 has written 
very wisely about cases of this class, and has pointed out that the 
temperature of the part may be taken as a safe guide in treatment. He 
says, " If the part be always overwarm, keep it quiet ; if it be generally 
cold or cool, it needs, and will bear, exercise and freedom from the- 
restraint of bandages, with friction and passive movements and other- 
similar treatment of the reviving kind." In some cases it may be well 
forcibly to liberate the joint by free motion under anaesthesia. 

Habitual Dislocation. — A marked tendency to recurrence may be- 
combated by prolonged immobilization of the joint if the injury is com- 
paratively recent, or by special treatment designed to thicken and shorten 
the capsular and periarticular tissues. Genzmer 2 has successfully em- 
ployed in two cases of recurrent dislocation of the shoulder repeated 
injections into the joint of the pure tincture of iodine. The needle was- 
introduced a finger-breadth below the coracoid process, and from seven to- 
ten minims were injected. The arm was then immobilized, and the 
injections repeated from five to seven times at intervals of three or four 
days. He recommends the same treatment for habitual dislocation of the 
lower jaw. 

Gerster 3 obtained a satisfactory result by arthrotomy with removal of 
a portion of the capsule. The patient was a girl, twenty years old, who 
had suffered a subcoracoid dislocation seven weeks previously. Reduc- 
tion was very easy, but the weight of the limb was sufficient to cause 
immediate recurrence. Finding the tendency to recurrence unchanged 
after he had kept the limb in place for five weeks by a plaster-of-Paris 
dressing, Dr. Gerster opened the joint by an anterior incision and re- 
moved from the relaxed inner side of the capsule a piece one inch long 
by half an inch wide. A counter incision was made in the posterior part 
of the capsule for catgut drainage, and the anterior wound closed. High 
fever, six hours later, rendered it necessary to open the wound and sub- 
stitute a rubber drainage tube for the catgut ; the wound was then treated 
open, and the tube removed at the end of the second week. The wound 
healed in eight weeks. The mobility of the joint was fair, and there was 
no tendency to recurrence. 

1 Paget: Clinical Lectures and Essays, p. 84. 

2 Genzmer: Centralblatt fur Chirurgie, 1883, p. 563. 

3 Gerster: N. Y. Surgical Soc, in N. Y. Medical Journal, April 5, 1884, p. 390. 



CHAPTEE VIII. 

ACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE 
A DISLOCATION. 

The complications or accidents that may be caused by the attempt to 
reduce a dislocation may appear during the attempt, as the immediate 
consequence of the manoeuvres employed, or subsequently as a more or 
less remote consequence of the changed conditions, the local injuries, or 
the inflammation produced by those manoeuvres ; and they may be local- 
ized at or near the dislocated joint, or may be the result of a local distant 
change or of a more diffused impression upon the organism. They may, 
therefore, be grouped as : 1st, primary local accidents ; 2d, consecutive 
local accidents; 3d, cases of hemiplegia, syncope, and sudden death. The 
first group comprises injuries of the skin, cellular tissue, muscles, vessels, 
nerves, and bones ; the second group includes suppuration in or about 
the joint, and oedema, gangrene, and paralysis consequent to injury to 
vessels or nerves. The third group includes those cases of shock or 
exhaustion, sometimes proving fatal, which have become exceedingly rare 
since the introduction of anaesthetics, and those others, that have come in 
their place, of death due to the anaesthetic itself. 

Instances of these accidents and references to them in the writings of 
the older surgeons — that is, previous to the beginning of this century, are 
not very numerous, and they indicate that while the accidents themselves 
were not infrequent they were commonly attributed to the dislocation 
rather than to the effort to reduce. The most recent and complete work 
upon the subject is a These de concours, by Dr. A. H. Marchand, Des 
accidents qui peuvent compliquer la reduction des Luxations trauma- 
tiques, published in Paris in 1875. Special articles upon the different 
kinds of injuries will be mentioned in the appropriate places. 

It is noticeable, on comparison of the cases that have occurred at dif- 
ferent periods, that while some varieties of the lesions are common to all 
times, with their varying methods of treatment, others are in a manner 
dependent upon the means by which the reduction has been attempted. 
Thus, violent traction is the sole cause of some ; manoeuvres, such as 
abduction and rotation of the arm, the principal cause of others ; violent 
pressure at or near the head of the bone, prolongation of the effort, and 
anaesthetics, each of its own peculiar varieties. Notwithstanding these 
differences, certain points may be recognized as common to the greater 
number, such as the age of the patient and the length of time during 
which the dislocation has remained unreduced. Injuries of the vessels 
have been most frequent in the old and in dislocations of long standing, 
and all the other accidents have, in recent times at least, been rarely seen 
except in connection with dislocations that have long remained unreduced 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 75 

or that have been complicated by much inflammatory reaction. The 
reasons for the greater liability to rupture of the arteries under these con- 
ditions are not obscure ; the loss of elasticity because of atheromatous 
change in the vessels in the old, and the adhesion of the vessels to ad- 
joining parts as a sequence of inflammation are a sufficient explanation, 
and the mechanical difficulties created by the contraction and readjust- 
ment of the torn tissues in old dislocations explain the others by the 
force that is required to overcome them. 

Integument. — The skin may be bruised or lacerated at a distance from 
the joint by the pressure of the cords through which traction is made, or 
near the joint by the pressure of the hands or instruments acting upon 
the dislocated end of the bone, or it may be torn across if the traction is 
exerted upon it rather than upon the bone. These lesions are seldom 
serious, and the former may usually be avoided by protecting the surface 
with thick layers of cotton or flannel. Transverse rupture of the skin 
between the points of extension and counter-extension is due to a faulty 
application of the force, by which it is exerted upon the skin alone and 
not upon the underlying bone. The skin is elastic and tough, and when 
unaltered by disease will support a very considerable strain, one far in 
excess of that commonly needed to overcome the contraction of a muscle, 
hut the traction may be so applied that it will act only upon the skin. 
Thus, if a broad band is strapped snugly about the middle of the arm 
and traction is made by a cord attached to it, it will draw the skin down- 
ward toward the elbow; and if at the same time the skin of the axilla 
and chest-wall is prevented by counter-extension from sharing in the 
movement, the intermediate portion is put upon the stretch and may tear, 
as in the following case reported by Mr. Hutchinson •} 

u In a case not long ago, of a six weeks' dislocation, we were com- 
pelled to desist because the skin had torn across the axilla. This curious 
accident occurred whilst we were trying the heel in the axilla method, 
and without the application of any unusual force, nor was the operator's 
boot on. Suddenlv the skin gave way from side to side, and a great 
transverse rent presented itself. The patient was a woman of fifty, of 
lax, flabby tissues. The wound healed quickly." 

Similar cases have been reported in dislocations of the shoulder 
(Malgaigne, 2 Smith 3 ), elbow (Marchand 4 ), and of the terminal phalanx of 
the great toe. 5 

In connection with this, as representing a less degree of the same 
injury, may be mentioned an experience of Malgaigne's (loc. cat., p. 
528) which he considered unique. He was attempting to reduce an 
intracoracoid dislocation in a very fat woman, and had increased the 
traction to 230 kilograms (about 500 pounds). The traction was made 
in the arm, the elbow being held at a right angle by an assistant. Just 
as Malgaigne changed the position of the limb in an effort to throw the 
bone into place the assistant loosed the forearm, and the bracelet slipped 
nearly to the wrist, dragging the skin along. The skin was not broken, 

1 Hutchinson: Lond. Med. Times and G-azette, 1866, i. p. 304. 

2 Malgaigne : Luxations, pp. 144, 501. 3 Smith : Lancet, July 6, 1878. 

4 Loc. cit., p. 22. 5 Gaz. Hebdomadaire, 1867, p. 398. 



76 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

but the underlying cellular tissue was extensively torn, and gangrene, 
fortunately limited in extent, followed. 

To guard against the occurrence of this accident the limb should be 
firmly grasped, if traction by the hands is used, at the enlarged distal 
end of the bone, so that the skin should not be drawn downward by the 
slipping of the hands, and the additional precaution may be taken to 
press the skin of the forearm (in the case of a shoulder dislocation) up- 
ward before the limb is grasped, and similar precautions suitable to the 
region should be taken at the point of counter-extension. If traction 
is made by a cord or band, it should be attached to the limb just above a 
bony prominence or enlargement which will prevent its slipping ; it 
should not be made fast simply by enclosing its loop in circular turns of 
a bandage which maintain their hold upon the skin by friction. For 
the same reason, if the attachment is made by means of strips of adhesive 
plaster, the strips should not extend far up the limb, and the gliding of 
the skin should be guarded against by snug circular turns of the bandage 
above bony enlargements. As the maximum of distention will be suf- 
fered by the portion of skin which covers and immediately adjoins the 
dislocated joint, and as this distention will increase as the bone yields to 
the traction and moves toward its cavity, the effect upon the skin of 
the counter-extending measures should be carefully scrutinized, and the 
bearing changed from time to time, if possible, so as to take advantage 
of the elasticity and mobility of the adjoining portions of integument. 

Sloughing of the skin, due to its compression against an underlying 
bone by direct pressure exerted to force the latter back into place, has 
been occasionally observed, in a dislocation of the astragalus, 1 and over 
the olecranon in an attempt made by a bonesetter to reduce a backward 
dislocation of the elbow. 

Emphysema of the Cellular Tissue. — On the basis of two cases, in 
which the condition of the parts was not shown by direct examination, it 
has been asserted that a gaseous tumor may form in the cellular tissue 
under the skin as a result of efforts to reduce a dislocation. In each of 
these cases the dislocation was of the shoulder, and the explanation 
offered in one was that the emphysema was due to air that had escaped 
from the lung after its rupture during and by the struggles and cries of 
the patient. The first case was reported by Desault; 2 he reduced by 
violent and prolonged traction a dislocation of the shoulder of six 
weeks' standing, in a man sixty years old. At the moment of reduction 
a tumor formed suddenly under the pectoral muscle, and soon filled the 
axilla ; the patient fainted, and the pulse was barely perceptible on the 
affected side. The tumor was well defined, elastic, not fluctuating ; the 
overlying skin was not discolored, and percussion gave a "sort of sound" 
(espece de bruit). On these symptoms rupture of the artery was ex- 
cluded, and diagnosis of emphysema made. In two weeks the tumor 
had entirely disappeared, leaving in its place a large ecchymosis. 
Pelletan 3 had a similar case, made the same diagnosis, incised the tumor, . 

1 Dauve: Rec. de Mem. de Med. et Chir. Milit., 1867, vol. xix. p. 143. 

2 Default: (Euvres Chirurgicales, vol. i. p. 380. 

3 Pelletan: Clinique Chirurg., vol. ii. p. 95, quoted by Malgaigne. 



ACCIDENTS IN SEDUCTION OF DISLOCATIONS. 77 

and lost his patient by hemorrhage ; the artery was found to have been 
ruptured. The only symptom in Desault's case which gives support to 
liis diagnosis is an alleged resonance in percussion, and that, in which an 
-error of observation might so easily be made, cannot be allowed to out- 
weigh all the others which point so plainly to rupture of a vessel. 

The third case cannot be so seriously criticised. Flaubert 1 reduced a 
dislocation of the, shoulder of five weeks' standing in a woman seventy 
vears old ; the first attempt was unsuccessful ; in the second traction was 
made by eight students, and the patient, who at first uttered vehement 
cries, seemed afterward to be upon the point of suffocating, and her face 
became purple and injected. An emphysema immediately appeared 
above the clavicle and spread over the shoulder to the middle of the back. 
She died on the eighteenth day, apparently in consequence of the tearing 
away of the lower four trunks of the brachial plexus at their attachment 
to the spinal cord. 

Rupture of the Muscles. — Under this head only those lacerations of 
the muscles will be mentioned which are occasioned, especially in old 
dislocations, by violent traction or by forcible, exaggerated, and long- 
continued manipulation of the limb. The cases in which the injury has 
been confirmed by autopsy are few, only those in which death has promptly 
followed in consequence of associated lesions or of the inflammation to 
which the violence has given rise. Yet, in another of Flaubert's cases, 
quoted by Marchand, 2 there seems to be no doubt that not only the mus- 
cles but also the ligaments and other soft parts were extensively torn. 
The case was one of dislocation of the elbow backward, twenty-seven days 
old, in which traction was made upon the forearm by seven assistants ; 
suddenly the parts seemed to yield and change their positions with a 
sound of tearing, and at the same moment a zone of narrowing or depres- 
sion appeared at the level of the joint with a bony prominence above and 
below. It seemed to all present that the muscles and soft parts covering 
the joint had been ruptured, leaving a gap two inches long. An enor- 
mous fluctuating swelling promptly appeared, the radial jxilse returned 
the next day, and the patient recovered. 

In the cases confirmed by autopsy the dislocation has always been of 
the shoulder, and the muscles most frequently torn have been the pector- 
alis major and the subscapularis. In a case reported by Petit the long 
portion of the biceps was torn from its tendon, and in one examined by 
Sir Astley Cooper, 3 a woman, fifty years old, who had died apparently 
from the violence used in reduction, " the pectoralis major was found to 
Tiave been slightly lacerated, and blood was effused among its fibres: 
. the supraspinatus was lacerated in several places ; the infra- 
spinatus and teres minor were torn, but not to the same extent as the 
former muscle. Some of the fibres of the deltoid muscle and a few of 
those of the coraco-brachialis had been torn, but none of the muscles had 
suffered so much injury as the supraspinatus." 

In a case briefly mentioned by Callender 4 " a bonesetter employed 



Flaubert : Repertoire d'Anat. et de Phys., 1827, quoted by Malgaigne. 
Marchand : Loc. cit., p. 20, and Malgaigne, loc. cit., p. 149. 
Cooper : Disloc. and Fract, Am. ed., p. 320. 
Callender: St. Bartholomew's Hosp. Eep., 1866, vol. ii. p. 101. 



78 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

twelve or sixteen men to pull at the arm of a man sixty years old, who 
was said to have dislocated his shoulder some time previously, and the 
following were the fatal results : the pectoral muscle was torn through, 
the plexus of nerves ruptured just below the clavicle, where also the 
artery was torn across. The bones of the forearm were dislocated at the 
elbow, and the bones of the arm and forearm fractured." 

Avulsion of a portion of a limb is fortunately a very rare accident. 
Except for one or two cases of avulsion of the thumb, known only by 
tradition, the only instance of complete avulsion is that in which Alphonse 
Guerin tore away the forearm at the elbow in an attempt to reduce a 
subcoracoid dislocation of the shoulder, The following is an abstract of 
a full report of the case published in the Bulletins de la Societe de Chi- 
rurgie, 2d Series, vol. 5, 1864, pp. 121 and 131. The patient was a 
woman of good health and constitution. The dislocation was not recog- 
nized until six weeks after its occurrence, when unsuccessful attempts 
were made to reduce it. All power of voluntary motion of the limb had 
been lost since shortly after the accident. At the time of admission to 
the hospital there was found a complete subcoracoid dislocation of the left 
humerus ; the limb hung motionless beside the body, and only the fingers 
could be slightly moved ; its cutaneous sensibility was dulled, temperature 
unchanged ; there was oedema of the lower part of the forearm and espe- 
cially of the hand ; skin faintly purplish ; sharp pains throughout the 
limb. Chloroform was given to complete resolution ; a broad bandage 
was passed under the axilla for counter-extension, and another made fast 
to the wrist and confided to four assistants. During the first attempt 
the second bandage slipped ; it was tightened, and traction again made, 
steadily and without much force. Suddenly, without warning, the limb 
separated at the elbow. The artery was tied, the lower two and a half 
inches of the humerus sawn off, and the stump trimmed. 

The rupture had taken place mainly through the joint, a small portion 
of each condyle remaining attached to the muscles of the forearm, and a 
portion of the olecranon to the triceps, and through the substance of the 
biceps and brachialis anticus ; the nerves had given way at distances 
above the elbow varying from five to seventeen inches, the latter being 
the musculo-cutaneous very much drawn out, and the brachial artery at 
three and a half inches. The muscles were softened and brown, espe- 
cially the pronator quadratus which was pulpy; the nerves were injected, 
with nodes at intervals ; the veins were dilated. The ends of the long 
bones were profoundly disorganized, with thinning of the compact shell 
and rarefaction of the spongy part ; they broke under slight pressure 
and could be easily perforated with the scalpel. The radius and ulna had 
been broken about half an inch above their lower articular surfaces. 
Microscopical examination showed degeneration of the nerves, muscles, 
and bones. 

The patient died on the thirteenth day, and the autopsy showed no 
change in the tissues of the other limbs ; the muscles of the left shoulder 
were normal, except the deltoid, the fibres of which were pale and degen- 
erated. The nerves were matted together in the axilla and firmly pressed 
against the head of the humerus ; above the point of compression they 
were normal, contrasting strongly with the parts below. 



ACCIDENTS IN KBDUCTION OF DISLOCATIONS. 79 

It is evident that the accident was favored by great trophic changes in 
the limb due to pressure upon the nerves in the axilla. 

Injuries of the Main Bloodvessels. — Although the earliest recorded 
cases of accidents of this class occurred at about the beginning of the 
eighteenth century, the subject did not receive the attention of systematic 
writers on surgery until after the publication, in 1827, of an article by 
Flaubert. 1 Malgaigne, in 1K55, discussed the subject at length in his 
work on dislocations, mentioning sixteen cases of all kinds, certain and 
uncertain. Cailender, 2 taking as a text his own fatal case, again collected 
and collated the known cases; and similar use was made of the material, 
and other cases added to the list by Le Fort, 3 Willard, 4 and Marchand. 5 
In 1882, Korte 6 reported three personal cases, and wrote a very full and 
valuable paper on the subject, containing forty-four supposed (actually 
thirty-eight ; see note below) cases of dislocation of the shoulder, in 
which the vessels had been seriously injured during the act of dislocation 
or of reduction ; and in 1884 Cras 7 reported a personal case of injury of 
the axillary artery, and added a few others to Korte's list. Strictly 
speaking, several of these cases should not be here considered, since in 
them the vessel was injured at the moment of dislocation and not during 
reduction, and in many others it remains uncertain whether the same 
objection might not be made to them. They are retained because they 
serve equally well with the others to further the study of most features 
of the subject. 8 

1 Flaubert : Mem. sur plusieus cas de luxations dans lesquels les efforts pour la 
reduction ont ete suivis d'accidents graves, Eepertoire d'anat. et de phys., 1827. 

2 Cailender : loc. cit., p. 96. 

3 Le Fort: Diet, encvclopedique des sci. med., article Axillaires. 
* "Willard: Phila. Med. Times, 1873, vol. iii. p. 721. 

5 Marchand : Des accidents qui peuvent compliquer la reduction des luxations 
traumatiques, These de concours, Paris, 1875. 

6 Korte : Arch, fur klinische Chirurgie, vol. xxvii. p. 631. 

7 Cras: Bull, de la societe de Chirurgie, 1884, p. 739. 

8 Reference to the original accounts, so far as I have been able to obtain them, 
shows several errors in the lists given by the above-mentioned writers. Sir Astley 
Cooper's case must be excluded because it is the same as Gibson's first case, having 
been simply quoted by Cooper without acknowledgment. 

Blackman's case must be excluded because it proved to be not a dislocation, but a 
fracture of the humerus. As it has been widely quoted, and is, indeed, given in 
detail as a dislocation by Dr. Hamilton (Fractures and Dislocations), an explana- 
tion of the manner in which the error arose may be of service. Blackman reported 
it as a dislocation in the Western Lancet, August, 1856, p. 469, and an abstract of 
this report was given in the Amer. Journal of the Med. Sciences, 1856, vol. xxxii. p. 
571, and is quoted by most writers. But on page 508 of the same (August) number 
of the Western .Lancet is a note by Blackman, which apparently had been overlooked 
by the maker of the abstract, giving the results of the autopsy, and showing the 
error in the diagnosis. The fracture was at the surgical neck, and the end of the 
shaft had been displaced upward, and lay in contact with the coracoid process; the 
head was still in the glenoid cavity, and had partly united with the shaft about an 
inch below its upper end. 

In Segond's case not only does the artery appear to have been wounded by a piece 
of the dish the patient was carrying, but it is doubtful even if the limb was dislocated. 

In Delpech's case it is recorded only that at the moment of reduction the patient 
grew pale, became unconscious, and died immediately, and there is nothing to show 
the cause of death. 

In Fano's the artery may have been simply compressed. O'Keilly's is the same as 
Adams's. The latter admitted the case into the hospital, the former operated upon it. 

A case which Cailender quotes, a man treated by a '* bone-setter, ' r does not deserve 



$0 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

I have met with only two recorded cases in which a large bloodvessel 
lias been injured in the reduction of any dislocation, except of the 
shoulder. These were both of the elbow, the cases of Flaubert and 
Michaux, quoted by Marehand and Malgaigne. The former has been 
already quoted under rupture of the muscles ; in the latter the patient 
was ten years old, and the dislocation was of the elbow backward and 
outward, the swelling was considerable, the radial pulse was present. 
Reduction was attempted on the day after the accident, and on the next 
following day, but without success. The last attempt was immediately 
followed by swelling of the elbow and by arrest of pulsation in the radial 
and ulnar arteries ; gangrene set in, and six days after the attempt the 
limb was amputated. The tendons of the biceps and brachialis anticus 
were found to have been forced by the manipulation around the external 
condyle to the posterior aspect of the humerus, accompanied by the rup- 
tured brachial artery and median nerve. 

The trustworthy recorded cases of injury to the larger vessels of the 
axilla in dislocation or reduction of dislocation of the shoulder are forty- 
seven in number. 1 Of these, the axillary vein alone was ruptured in 
three (Froriep, Price, Hailey), although I think the last one doubtful, 
and the artery and vein together in two (Platner, Baum). 2 In most of 
the others, the axillary artery or one of its branches was injured, but in 
some the source of the hemorrhage remains uncertain. In thirty-two 
cases death or amputation of the arm furnished the opportunity to examine 
the region and determine the character of the lesion ; this, in some cases, 
was a complete or partial rupture of all the coats of the artery, or of the 
inner and middle coats alone, with subsequent formation of a circum- 
scribed aneurism. 3 In other cases the vitality of the wall appears to have 
been diminished or destroyed by direct pressure, and this to have been 
followed, after the lapse of a few days, by rupture (Warren), or, still later, 
by the formation of an aneurism. In Gibson's second case an aneurism 
appears to have formed in consequence of the earlier attempts to reduce, 
and then itself to have been ruptured when Gibson effected reduction. 
Rupture always appears to have taken place quite high up, and usually 
at the point pressed upon by the head of the humerus. Callender found 
it necessary to divide the pectoralis minor to reach it. In the fatal cases 
of injury of the vein alone the vessel was torn completely, or almost com- 
pletely, across. In Baum's case both artery and vein were partly torn 
"by a broken piece of the new bony socket that had formed about the head 
of the humerus. The artery was tied above the origin of the long 

ix) be grouped with those treated by professional surgeons, although the force em- 
ployed — traction by twelve or eighteen assistants — was not much in excess of that 
recorded in some of the other cases, or of what I have myself seen employed. Not 
only the artery, but also the muscles were torn, and the humerus was broken. 

Green's case (Lancet, 1825, vol. viii. pp. 189 and 283) is quoted as one of recovery 
after ligature of the subclavian, but the reports end on the eighteenth day with the 
ligature still in place, and after a free hemorrhage on the thirteenth day. 

1 For the references, see the list of cases at the end of this section, p. 88. 

2 Possibly to these may be added Volkmann's case of wound of the axillary vein, 
thought to have been caused by a splinter of bone. The wound was discovered 
during an operation to excise the head. (See Chapter XVIII.) 

3 It is possible that this rupture may be followed by obliteration of the artery at 
the wounded part. Scarpa held this opinion (Hodgson, Diseases of Arteries, p. 488). 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 81 

thoracic, and a second ligature was subsequently placed on it at the level 
of the lower border of the pectoralis major. 

In five cases (Callender, Despres, and Korte's three) only a small (one- 
sixth of an inch) oval opening was found on the anterior wall of the 
.artery, and was thought to have been produced by the tearing off of a 
branch, the subscapular or circumflex. 

In Gartner's ease the opening in the artery is described as funnel- 
shaped, but the tumor was small, formed slowly, and presented the 
common signs of aneurism, so that it seems probable that what he de- 
scribes as the opening included also the neck of the aneurismal sac. In 
other cases the subscapular (Lefeuvre) or the circumflex artery (von Pitha) 
was torn across at or near its origin. These last-named eight cases form 
a considerable proportion of the whole number, and are of great impor- 
tance because they explain the persistence of the radial pulse noted in 
several of the histories. In Parker's the swelling was at the axillary 
border of the scapula behind, " near the situation of the dorsal scapular 
artery or the subscapular at the junction of the two." 

Of thirty-one cases in which the age of the patients is given, in twenty 
they were more than forty years old. The youngest was twenty (Gart- 
ner), the oldest eighty-six (Sands). In very few of the cases it is noted 
that the arteries were atheromatous, although the advanced age of many 
of the patients makes it probable that the elasticity of the vessels was 
diminished. 

In more than half the cases the dislocation was recent — less than three 
weeks. In not more than one-third of them is it reasonably certain that 
the lesion was caused during reduction; in three cases it was certainly 
caused by the dislocation ; in the remainder the cause is obscure. To 
these latter belong those cases in which the reduction was promptly 
effected, and without the use of much force or of exaggerated positions of 
the arm. 

In many of the others the attempt to make reduction was greatly pro- 
longed or several times repeated, and the force used was very great or 
improperly applied. This last criticism is probably applicable to the 
earliest four cases (Verduc, Petit, Platner, and Bell), about which nothing 
is known except that death was caused by hemorrhage. In one of them 
(Bell) the use of the ambi is mentioned, and it is probable that it or the 
method of the door or ladder was employed in all. 

In some the injury was evidently caused by excessive traction (Gibson, 
traction by five or six assistants in one case, by pulleys for nearly two 
hours in the other ; Leudet, eight assistants) ; in others by faulty 
manoeuvres, such as extreme abduction or elevation of the arm, rotation, 
and circumduction ; in others again apparently by direct compression of 
the vessel against the underlying bone, as by the booted heel in the axilla 
(Warren, Rivington), or possibly by the thumbs (Panas). 

Leaving aside the earlier cases in which faulty methods no longer in use 
were employed, and those old dislocations in which the relations and con- 
nections had been permanently changed by fibrous or bony tissue of new 
formation, it becomes evident that in dislocation of the shoulder the acci- 
dent is most to be apprehended when the elbow is raised in abduction to 
the height of the shoulder, or is carried, as in Callender's case, across the 



82 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

chest and face in a wide movement of circumduction ; and for this reason, 
that in these movements the dislocated head of the bone is turned down- 
ward into the axilla, and the vessels which lie upon its inner side are 
pressed down before it and forcibly put upon the stretch, while those 
branches which run almost directly outward, the subscapular and circum- 
flex, and are fixed to the tissues amid which they branch, are directly 
and forcibly elongated. Even when the head of the humerus is in its 
socket the axillary vessels are put upon the stretch when the arm is 
widely abducted, as can be readily verified during an operation for the 
removal of the axillary glands, or, still more simply, by observing the 
arrest of the radial pulse when the arm is raised and carried back- 
ward ; and there are several cases on record in which this movement 
alone has resulted in the formation of an axillary aneurism or in rupture 
of the axillary artery. 1 Although in dislocation inward the limb is 
shortened by being abducted, yet the artery is not thereby relaxed, but,, 
on the contrary, is still further stretched around the head of the bone. 
Jossel, 2 in a recent case in which death was caused by associated injuries, 
found the "nerves of the brachial plexus, especially the circumflex nerve 
and the subscapular artery, greatly stretched by the head of the humerus ; ,? 
and, according to Korte (loc. cit., p. 640), he found in another case of 
recent dislocation the subscapular artery torn. 

In his remarks on the case at the Sheffield Infirmary 3 in which the 
artery was torn across during an unsuccessful attempt to reduce a dislo- 
cation of six weeks' standing, and an incision was made through which 
each end of the torn artery was tied, Mr. Jackson says: "One thing was 
noticed on cutting into the axilla : the extreme tension caused by the 
pressure of the head of the humerus on the vessels and nerves when the 
arm was raised above the shoulder." This patient died two days after 
the operation. 

In some of the cases in which it is certain or probable that the injury 
to the vessel was inflicted at the moment of dislocation, it is noted that 
the latter was produced while the arm was widely abducted — that is, 
under circumstances in which the head of the humerus would be driven 
downward and inward. 

If the dislocation is an old one, and especially if there has been much 
inflammatory reaction, and the vessels have become firmly adherent to 
the bone, or imbedded in unyielding cicatricial tissue, the liability to rup- 
ture is increased, because of the loss of elasticity occasioned by the latter 
condition, and because of the limitation of the strain to a shorter seg- 
ment of the vessel in the former. If, in addition, the distensibility of 
the vessel has been further reduced by atheroma, the danger is still 
greater ; and this last predisposing cause may properly be deemed suffi- 
cient to lead to the rupture, even when the traction is slight and the 
manoeuvres are confined within a narrow range. 

In Anger's case, fracture of the head (?) of the humerus coexisted ; in 

1 Cases of Pelletan and Paget, and specimen in museum of St. George's Hospital; 
Callender, loc. cit., pp. 103 and 107. 

2 Deutsche Zeitschrift, 1880, vol. xiii. p. 177. 

3 British Med. Journal, Feb. 3, 1883, p. 207. 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 83 

Mash's, tAvo pieces had been chipped off the head of the humerus, and 
were lying in the glenoid cavity. In several others fracture of the 
greater tuberosity of the humerus or of the rim of the glenoid cavity is 
noted ; the former of these two complications is common in inward dislo- 
cation of the humerus, and could have had no direct influence in causing 
the injury of the vessels ; the latter, also, was probably without influence, 
since the vessels are pushed away from the scapula, and the fragment 
remains attached to it. 

The symptoms at the beginning present two widely different forms ; in 
one, the less common, a tumor presenting many of the signs of an 
encysted aneurism appears in the axilla a few days or weeks after the 
reduction, and increases in size rather rapidly ; if not successfully treated, 
it soon involves the skin and ruptures externally. In the other form, 
the more common, a diffused fluctuating swelling, without bruit or pulsa- 
tion, appears immediately, or within a few hours, in the axilla, raising 
the pectoral and deltoid muscles, or is, perhaps, most prominent poste- 
riorly, and in most cases promptly reaches a large size, even that of the 
adult head (Lister) ; the radial pulse sometimes persists. The only 
exception to rapid growth among the recorded fatal cases is Korte's third 
case (loc. cit., p. 636), in which the extravasated blood disappeared slowly, 
leaving a firm, non-pulsating lump, as large as a walnut, in the course of 
the axillary artery, which a surgeon supposed to be a lymphatic gland, 
and undertook to extirpate nearly five months after the accident. It 
proved to be an aneurism containing much stratified clot ; the axillary 
artery was tied above and below, and the patient died. 

In several cases the patients died promptly after the accident, some- 
times after profound syncope, sometimes (Gibson's first case) after a short 
period of apparent well-being, with symptoms of shock or acute ansemia. 
In two, which finally ended in recovery (Sands, Agnew), the patients 
were at first greatly prostrated, and death by syncope threatened. In 
another (Mash's) gangrenous emphysema developed in the arm, and the 
patient died forty hours after the reduction. In this case the inner and 
middle coats of the artery were torn across "just beyond the point of 
origin of the dorsal scapular branch." The radial pulse was at first per- 
ceptible, but had ceased the next morning. 

In most of the others the swelling increased, and, in a longer or shorter 
time, ruptured spontaneously, or was threatening to rupture when opera- 
tive interference (puncture, incision, or ligature of the subclavian) was 
resorted to. The longest period was in Bellamy's case, six months after 
reduction, and even in this case the first hemorrhage occurred five weeks 
after reduction. 

In the cases that recovered without operation (Agnew, Sands, Mal- 
gaigne, Desault, Anger, Nekton's second case 1 ), the swelling subsided, 
and the ecchyruosis was slowly absorbed. Agnew's patient was discharged 
in ten days, Anger's and Desault's in a fortnight, Malgaigne's was well 
on the twenty-second day, and Sands's, a woman eighty-six years old, 
made a slow recovery. In three of them (N elaton's, Anger's, Sands's 2 ) 

1 Referred to by Anger and Le Fort, loc. cit. 

2 Dr. Sands's patient died in May, 1885. The injury proved to have been of the 
axillary artery, which was occluded at a point a quarter of an inch above the origin 



84 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

the diagnosis of rupture of the axillary artery was made. Desault's 
diagnosis was "emphysema of the cellular tissue;" the case has been 
quoted above, under that head. Malgaigne and Agnew made the diag- 
nosis of rupture of the axillary vein. 

I think there is reason to doubt the correctness of the diagnosis in 
the last three cases, certainly in Desault's and Malgaigne's, for it was 
avowedly based on the persistence of the radial pulse, and, although it 
is not so stated in the report of Dr. Agnew's case, it seems fair to assume 
that the same persistence of the pulse which is noticed in the report was 
also the basis of his diagnosis. As has been already mentioned, rupture 
of the subscapular or circumflex artery has several times presented similar 
symptoms, and, as in Mash's case just quoted, the radial pulse may even 
persist after rupture, of the inner and middle coats of the axillary artery 
itself. Pelletan had a case similar to Desault's, made the same diagnosis, 
and incised the tumor ; the patient died of hemorrhage, and the artery 
was found to have been ruptured. 

In the two cases in which rupture of the vein alone was demonstrated 
post-mortem (Froriep, Price), the patients died promptly, in an hour 
and a half and on the following day respectively. In the third case, 
Hailey's, in which this lesion is said to have been proved by the autopsy, 
the account of the examination is very unsatisfactory, and leaves it, I 
think, quite uncertain what the actual injury was. The patient was a 
man fifty-nine years old ; the dislocation was caused by a fall from a 
wagon, and was very easily reduced. The symptoms were, first, pain in 
the wrist, then, after a few days, swelling of the shoulder and oedema of 
the arm ; at the end of two months a tumor appeared between the acro- 
mion and coracoid (sic), and death by exhaustion a few days later. The 
tumor was blood-clot, more than two pounds being removed from the 
axilla. 

In Dr. Morgan's case "it was impossible to detect the source of the 
hemorrhage" at the autopsy, and it was attributed to the rupture of 
many small veins. This explanation also, I think, may well be questioned, 
for in this case too the radial pulse persisted, and at that time no cases 
had yet been reported in which similar symptoms had been shown to be 
caused by rupture or avulsion of a branch of the main artery, If, as 
seems probable from the account, and in view of the ignorance of this 
fact, the examination was mainly directed to the condition of the veins, 
it is not unlikely that rupture of an arterial branch may have been over- 
looked, especially since the symptoms were not unlike those of some of 
the other cases in which this rupture was demonstrated (Despres, Korte's 
second case). The symptoms and course of this case were, in brief, as 
follows : 

The patient was a man fifty-four years old, the dislocation subcoracoid, 
the reduction immediate, under chloroform, with the heel in the axilla. 
During the first week "there was nothing to be noticed but the ordinary 
swelling attending such a dislocation. This swelling, instead of subsiding, 

of the posterior circumflex. The specimen was presented at the meeting of the New 
York Surgical Society May 26, 1885, and a description of it will be found in the 
report of the proceedings. ~(N. Y. Med. Journal, and The Medical News, June 13, 

1885.) 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 85 

increased, and this somewhat rapidly toward the end of the first week. 
There was also some purple discoloration about the inner and posterior 
parts of the shoulder. Still there were no appearances which might not 
attend an ordinary bruise or laceration about the part. But, in the 
course of the following week, enormous swelling had come on, extending 
from the elbow up the arm, and over the chest to the level of the outer 
third of the clavicle, and over the scapula." The swelling was soft and 
fluctuating ; the skin in places dark purple and thin ; the radial pulse 
was natural. Fever, with slight shivering and one distinct chill. " About 
the third or fourth week an incision was made in the arm, and the hand 
passed up into the cavity, which contained an enormous amount of blood, 
chiefly coagulated, extending under the pectoral muscles, down the side 
of the chest, and behind over a great part of the scapula, and communi- 
cating with the shoulder-joint. The subclavian and axillary arteries 
c >uld be felt." The man died with symptoms of septicaemia. 

In Korte's second case (loc. cit., p. 635) the patient was fifty-two years 
old, the dislocation forward and inward. Several unsuccessful attempts 
to" reduce were made during the sixth month, and the last was followed 
by the gradual appearance of a non-pulsating swelling under the pectoral 
muscle, oedema of the arm, and sharp neuralgic pain. Radial pulse. 
The patient became feverish, the tumor softer, the skin thin, and at the end 
of six weeks it ruptured spontaneously. The hemorrhage was arrested 
with a tampon, and the patient died shortly afterward. The autopsy 
showed a large cavity occupying all the space under the pectoralis major, 
and filled with large blood-clots. On the outer and front side of the 
artery, 4 centimetres below the clavicle, was a transverse opening meas- 
uring 0.4 by 0.3 centimetre (one-sixth by one-eighth inch), thought (loc. 
cit., p. 650) to have been produced by the tearing off of an arterial 
branch. 

In Despres's case there was the same swelling, slowly increasing and 
becoming fluctuating, oedema of the arm, and persistence of the radial 
pulse. In addition, a bruit was audible after the tenth day, and the 
swelling subsequently pulsated at times. An operation for ligature of 
the subclavian was done on the fifty -fifth day, and was followed by arrest 
of the pulsation, but, after the patient died, on the fifty-fourth day, it was 
found that the ligature had been placed upon a nerve immediately over- 
lying the artery. The common trunk of the circumflex arteries was found 
to have been torn off at its origin. 

On the other hand, in Korte's first case, in which the lesion proved, 
post-mortem, to be a similar opening upon the side of the axillary artery, 
and of almost exactly the same size, pulsation in the brachial and radial 
arteries was barely perceptible two months after the accident, when the 
patient first came under observation with an enormous pulsating swelling 
of the shoulder filling the axilla and extending up to the clavicle. 

These histories show, and many of the others might be quoted in con- 
firmation, that, although the diagnosis, so far as the general nature of the 
accident, rupture of a bloodvessel, is concerned, does not long remain 
obscure, the identity of the injured vessel cannot always be determined. 
If the tumor pulsates, the diagnosis of rupture of an artery may be made; 
and if, in addition, the radial pulse is present, it is extremely probable 



8b ACCIDENTS IN SEDUCTION OF DISLOCATIONS 

that the injured vessel is not the main artery, but that one of its branches, 
probably the subscapular or circumflex, has been ruptured or torn off at 
its origin. Beyond this it does not seem at present possible to go with 
much certainty, although the great preponderance of arterial lesions in 
the known cases^-26 out of 28, or, adding Hailey's and de Morgan's, 
out of 30, or, again, adding Platner's and Braun's, in which both artery 
and vein were torn, out of 32 — makes it highly probable in any given 
case that an artery and not the axillary vein has been torn. 

Of the remaining 15 cases, 6 recovered without operation (Desault, 
Malgaigne, Nelaton's second case, 1 Anger, Agnew, and Sands) and have 
been already discussed. Nelaton, Anger, and Sands made the diagnosis 
of rupture of an artery. In 8 (Warren, O'Reilly, Green, Volkmann, 
Letievant, Cras, Archangelski, and Parker) the subclavian was tied; in 
7 of them with success; in 1, Green's, the result is not known. In 1, 
Dickson, pulsation was arrested by digital pressure on the subclavian con- 
tinued for eight hours ; a year later the tumor was again pulsating, and 
digital pressure was again made, apparently for a week ; three years later 
there was no trace of the tumor. 

In the last 7, and in 3 of the first 6, it seems reasonably certain that 
an artery was injured, for pulsation of the swelling is noted in every 
account that is given in detail, and such was the opinion of the surgeons 
who treated them. The record, then, may be made as follows : Of 47 
cases, an artery (the axillary or a large branch) was ruptured in 88, the 
artery and vein in 2, the vein alone in 2, in 2 dissection failed to reveal 
the source of the hemorrhage, and in 3, in which the patients recovered 
without operation, the symptoms do not justify a positive diagnosis. 

The terminations were as follows : 15 recoveries, 31 deaths, and in 1 
(Green's) the result is unknown ; 20 received no operative treatment ; of 
these 6 recovered and 14 died. 2 In 16 the subclavian was tied, with 6 
recoveries, 8 deaths, and 1 unknown result. In 1 a cure was effected by 
digital pressure on the subclavian. In 6 an incision was made in the 
axilla, and the artery tied above and below the point of rupture ; all died. 
In 4 the limb was articulated; 1 recovery, 3 deaths. The treatment in 
the cases that recovered without operation was simply compression of the 
swelling and immobilization of the arm, with the application of ice in 
Malgaigne' s, and compression of the subclavian artery in Agnew 's. 

In drawing inferences from these results, it must be borne in mind 
that in many of the cases in which operations were undertaken non- 
operative treatment had previously been employed, and had resulted in a 
condition that made an operation necessary. Thus, using only those 
cases in Avhich the record is sufficiently detailed, of the 17 cases of liga- 
ture or compression of the subclavian, in 10 the operation was done after 
the lapse of several weeks or even months, in 1 on the third day, in 1 on 
the tenth day, and in 5 the length of the interval is not known. Of the 
4 disarticulations, in 1 the operation was at a late date, in 1 five days 

1 After rupture of the tumor without hemorrhage, and suppuration of the sac and 
shoulder-joint. See Korte, loc. cit., p. 655. 

2 Possibly Korte's second case should be included among the recoveries. 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 87 

after the accident, and in 2 unknown. Of the 6 treated by incision and 
double ligature of the axillary artery, the operation was done promptly in 
2, and after a long interval in -i. Consequently the results of non-opera- 
tive treatment may be tabulated as follows : Of 35 patients, 6 recovered, 
14 died, and 15 (with 10 deaths) subsequently underwent operation, either 
because death by hemorrhage threatened, or because of the existence of a 
growing aneurism. 1 A fair inference is that conservative treatment may 
properly be tried at first, but should not be prolonged if the symptoms do 
not promptly yield ; and, secondly, that, in case of resort to operation, 
ligature of the subclavian artery or disarticulation at the shoulder is to be 
preferred to incision of the sac and double ligature of the artery. 

Experience with arteries wounded under other conditions has shown 
that they will sometimes quite readily heal, or the opening made into 
them will close, under pressure accurately made at the point of injury, 
;and it would therefore be proper to attempt to treat this injury by direct, 
limited pressure. Whether or not it would be possible to recognize the 
wounded point and make efficient pressure directly upon it cannot be said, 
since the attempt does not appear to have been made. In default of such 
limited pressure, general compression of the swelling in the axilla seems 
to be the only resource short of operation. The common treatment of 
ruptured artery, incision and double ligature of the vessel, was imme- 
diately resorted to in only two of these cases, Lister's and the one at the 
Sheffield Infirmary. Both were promptly fatal. 

An important question arises from these facts in connection with the 
treatment of dislocation of the shoulder : How far does the possibility of 
the occurrence of this accident affect the choice of a method of reduction ? 
and also concerning the propriety of attempting reduction in cases that 
are not recent. 

In the reduction of recent dislocations, these accidents show that ab- 
duction of the arm especially should be avoided, as also circumduction, 
violent traction, and rough pressure in the axilla. Kocher's method by 
manipulation appears well adapted to avoid the danger. It is also to be 
remembered that the injury to the vessel may be caused by the disloca- 
tion itself, and its symptoms may be masked by the swelling commonly 
present during the first few days. 

In old dislocations the probability of the occurrence of the accident is 
increased by the more forcible measures usually necessary to break up 
the adhesions that bind the bones in their new relations ; and, while it 
may be proper in many cases to make the attempt to restore the limb to 
usefulness, the possibility creates another reason for abstention when the 
patient is old, the duration of the dislocation long, and the adhesions 
firm. Even a dislocated arm may be very useful, and the fatality of this 
accident, more than seventy per cent, of deaths, may well cause the sur- 
geon to hesitate to incur the risk merely for the sake of ameliorating a 
condition which does not endanger life and is quite compatible with 
activity and usefulness. 

1 Korte's second case is an exception ; an error in diagnosis led to an operation 
after the aneurism had apparently undergone spontaneous cure. 



88 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

List of Cases. 
A. Fatal without Operation. 

1. Verduc (Malgaigne, Des luxations, p. 149) ; artery wounded ; no treatment;: 
death by hemorrhage. 

2. Petit (Malgaigne, Des luxations, p. 149); artery wounded,- no treatment; 
death by hemorrhage. 

3. Pelletan (Malgaigne, Des luxations, p. 149); artery wounded; puncture;; 
death by hemorrhage. 

4. Platner (Malgaigne, Des luxations, p. 151) ; artery and vein ; death by 
hemorrhage. 

5. Leudet (Malgaigne Des luxations, p. 149); artery; 57 years. Dislocation 
11 days. 

6. Froriep (Malgaigne, Des luxations, p. 151); vein; 26 years. Dislocation 
3 weeks. 

7. Gibson, I., Surgery, i. p. 325; 50 years. Disloc. 2 months. Death in a few 
hours. 

8. Price, quoted by Callender, p. 107 ; vein. Death on following day. 

9. Korte, L, Arch, furklin. Chir., vol. xxvii. p. 631; artery; 25 years. Disloc. 
recent. Puncture. 

10. Korte, III., Ibid. ; artery; 52 years. Disloc. 5 J months. Rupture. 

11. Mash (Carruthers), Brit. Med. Journ., 1872, i. p. 526; artery; 38 years. 

12. Haily, Ibid., 1863, ii. p. 634 ; 59 years. Disloc. recent. 

13. De Morgan, Ibid., 1872, i. p. 54; 54 years. Disloc. recent. Incision. 

B. Ligature of Subclavian. 

14. Green, Lancet, 1825, vol. viii. pp. 189 and 283 ; 33 years. Disloc. recent. 
Result unknown. 

15. Warren, Med. -Chir. Trans,, vol. xxix. p. 25; 30 years. Disloc. recent. 
Recovery. 

16. Gibson, II., loc. cit., p. 334; 35 years. Disloc. 9 weeks. Death. 

17. O'Reilly (Adams), Cyclop, of Anat. and Phys., vol. iv. p. 616; 50 years. 
Disloc. recent. Recovery. 

18. Nelaton, I., Path, chir., ii. p. 368. Disloc. old. Death. 

19. Rigaud, Diet, encyclop., art. Epaule ; artery ; 23 years ; death. 

20. Von Pitha (Korte", loc. cit., p. 649) ; artery; death. 

21. Volkmann (Korte, loc. cit., p. 656). Recovery. ■ 

22. Panas (Marchand, p. 52) ; artery. Dislocation recent; death. 

23. Despres, Bull, de la Soc. de chirurgie, 1878, p. 116 ; artery ; 40 years. 
Recent; death. 

24. Gartner, Schmidt's Jahrb., 1871, vol. cli. p. 304; artery; 20 years. Recent; 
death. 

25. Letievant, Bull, de la Soc. de chir., 1884, p. 748. Recent; recovery. 

26. Lefeuvre, Ibid., p. 750 ; artery ; 52 years. Recent ; death. 

27. Cras, Ibid., p. 739; 45 years. Recent; recovery. 

28. Archangelski, Centralblatt fur chirurgie, 1885, p. 383. Dislocation habitual ; 
aneurism appeared after unsuccessful attempt on 4th day, and increased after a 
second attempt in 4th week. Subclavian tied below the clavicle ; recovery. 

29. Parker, Lancet, 1885, i. p. 704. F. 36 years. Disloc. 7th week. The rup- 
tured artery was apparently the subscapular. 

C. Double Ligature — all Fatal. 

30. Callender, St. Barthol. Hosp. Rep., vol. ii. p. 96; artery; 61 vears. Disloc. 
old. 

31. Wutzer, Arch, fiir klin. Chir., vol. x. p. 308. 

32. Korte, II., loc. cit.; artery; 29 years. Disloc. recent. 

33. Lister, Edinb. Med. Journ., 1873, p. 829; artery ; 58 years. Disloc. 8 weeks. 

34. Rivington, Brit. Med. Journ., 1872, i. p. 420 ; artery; 71 years. Disloc. 
recent. 



ACCIDENTS IN REDUCTION OF DISLOCATIONS, 89 

35. Sheffield Inf., Ibid., 1883, i. p. 207; artery; 62 years. Disloc. 6 weeks. 

36. Baum, Deutsche Klinik, 1867, p. 431 ; artery and vein. Lig. of axillary 
(possibly double). 

D. Digital Pressure. 

37. Dickson, Keney, Philad. Med. and Surg. Reporter, 1882, vol. xlvii. p. 256, 
M. 24. Recent ; recovery. 

E. Disarticulation at Shoulder. 

38. Jiinken, Arch, fiirklin. Chir., vol. x. p. 313; artery. Unsuccessful attempt 
to apply double ligature ; recovery. 

39. Bell (Malgaigne and Callender). Death. 

40. Ledentu, Bull, de la Soc. de chir., 1877, p. 187; artery. Disloc. recent; 
death. 

41. Bellamy, Lancet, 1880, ii. p. 260; artery; 55 years. Disloc. 7 weeks; 
death. 

F. Recovery without Operation. 

42. Desault, (Euvres chirurgicales, vol. i. p. 380 ; 60 years. Disloc. 1 \ month. 

43. Malgaigne, loc. cit., p. 150 ; 44 years. Disloc. 2 months. 

44. Anger, Bull, de la Soc. de chir., 1878, p. 122; 54 years 

45. Nelaton, II., Ibid. 

46. Agnew, Willard in Phila. Med. Times, 1873, p. 721 ; 60 years. Disloc. 6 
weeks. 

47. Sands, N. Y. Med. Record, 1880, p. 45 ; 84 years. Disloc. 7. weeks. Au- 
topsy in the proceedings of the New York Surgical Society, May 26, 1885, in 
N. Y. Med. Journal and in The Medical News, June 13, 1885. 

Injuries to Nerves. — These also have been far more frequently ob- 
served at the shoulder than elsewhere, and there is the same difficulty in 
many of the recorded cases in determining whether the injury was caused 
by the dislocation or by the manoeuvres employed to effect a reduction. 

The injury may consist in direct compression of the nerve against the 
bone, as in the attempted reduction by the method of the door or ladder 
or by the heel in the axilla, or in forcible elongation or complete rupture 
of the nerve by traction upon the limb, or such change in its position 
that the nerve is stretched around the head of the bone, or in avulsion 
of the nerve from the spinal cord. As the autopsies are few in number 
our knowledge of the lesions is mainly clinical. In a case quoted in the 
preceding section, one of rupture of the brachial artery near the elbow, 
the median nerve was also ruptured ; and this double injury has been 
several times encountered in compound dislocation of the elbow. 

In a case reported by Flaubert, 1 and mentioned above in the section 
on Emphysema, a dislocation of the left shoulder five weeks old in a very 
stout woman aged seventy years, reduction was accomplished with diffi- 
culty after prolonged traction upon the arm by eight assistants. Besides 
the emphysema extending over the neck and back, there were syncope 
lasting an hour, cloudiness of vision, paralysis of the right arm, and left 
hemiplegia with loss of sensibility in the left arm but with pain referred 
to it. Thirty-six hours later there was sharp pain in the back of the 
head and neck and in the ears; pain also in the left thigh, in which 
sensation was better than in the right; the left arm was insensitive, with- 

1 Marchand : Loc. cit., pp. 25 and 67. 



90 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

out pain, and motionless ; the right arm numb and somewhat weakened ; 
pulse rapid, skin warm. The next day the pupils were dilated and did 
not respond to light. On the seventeenth day the respiration was embar- 
rassed, the skin hot, pulse rapid, prostration great ; and on the nineteenth 
day death. The autopsy showed the lower four pairs of the brachial 
plexus on the left side to have been torn away from the spinal cord ; 
their torn ends plainly showed the delicate filaments by which they took 
their origin, and the ganglions on the posterior roots could be distin- 
guished. The first pair had suffered no injury. The spinal dura mater 
was of a dark brown-red color, and the cord, at the point where the 
nerves had been torn away, was changed into a reddish-brown pulp in 
which the gray and white substances seemed mingled. 

The two following cases recorded by Flaubert 1 bear a close resemblance 
clinically to this one. 

In a man, fifty years old, with a dislocation of the shoulder dating from 
a fortnight before, traction by three assistants caused numbness and pain 
in the hand and wrist ; a second attempt, with six assistants, instantly 
caused numbness in the corresponding leg, and the reduction was aban- 
doned. The following night there was sharp pain in the lower cervical 
vertebrae, subsequently extending to the dorsal region. The arm remained 
almost completely paralyzed. 

A dislocation of the shoulder seven weeks old in a woman sixty-four 
years of age was reduced by traction made by five assistants. At the 
moment of reduction the patient felt a sort of rupture at the wrist, fol- 
lowed by a quivering that extended to the lower third of the arm and by 
complete hemiplegia and great diminution of sensation on the same side, 
especially in the arm. The lower limb regained its power, but the arm 
remained paralyzed and atrophied. 

Gerdy, 2 while trying to reduce a dislocation of the shoulder by forcible 
traction with pulleys, the arm being held at right angles with the body, 
observed a tense cord under the skin on the inner side of the arm. 
Thinking it was the median nerve, he abandoned the attempt and made 
two experiments upon cadavers to determine the effect of tractioi) upon 
the nerves and vessels. In each he was able to make a similar cord mani- 
fest on the inner surface of the arm, and found on dissection that it was 
the median nerve much stretched and carried inward. The brachial 
artery was much less tense. The traction was then increased until the 
nerve broke ; the other nerves, the brachial plexus, and the vessels 
remained uninjured. 

In other cases the effects, as indicated by the symptoms, have been 
limited to the limb, arm or leg, or to portions of it. 

Erichsen 3 quotes from Billroth a case of dislocation of the shoulder of 
nine months' standing which had been accompanied by partial paralysis of 
the arm and some atrophy. The reduction was followed by total paralysis. 
Le Bret 4 reported one which occupies a position intermediate between 
this class and the preceding : a soldier dislocated his right shoulder ; 

1 Quoted by Malgaigne : Loc. cit., pp. 158, 159. 

2 Marchand : Loc. cit., p. 71. 

3 Erichsen: Surgery, Am. ed., vol. i. p. 415. 

4 Le Bret: Soc. de Biologie, 1854, p. 119. Quoted by Weir Mitchell. 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 91 

reduction was immediately made by traction, and was followed by paralysis 
of motion in the entire arm, loss of sensation below the elbow and on the 
right side of the neck, and by ptosis and dimness of vision on the same 
side. In most of the more recent recorded cases the history leaves it in 
doubt whether the paralysis was caused by the dislocation or by the re- 
duction. In the older cases, in w r hich the rough method of the door, 
ladder, or ambi was employed for reduction, there can be little doubt that 
the paralysis was commonly caused by the reduction. Petit 1 says he has 
seen it several times, and La Motte 2 describes a striking instance. At 
the shoulder the nerve most frequently affected is the circumflex ; Mar- 
chand thinks this nerve is commonly injured by the dislocation, the others 
by the reduction. Instances of injury in other dislocations than those of 
the shoulder are rare. Hutchinson 3 describes a case of ischiatic disloca- 
tion of the femur reduced by manipulation under ether, followed by com- 
plete anaesthesia of the limb below the knee except on the inner side of 
it and of the foot. 

In a case of anomalous form quoted by Dr. Hamilton, 4 a recent dislo- 
cation downward and backward between the tuberosity and spine of the 
ischium received into the Pennsylvania Hospital in 1835, " on the fol- 
lowing day, the muscles of the patient having been sufficiently relaxed 
by suitable means, the pulleys were applied ; but after a second attempt, 
some of the bands having given way suddenly, the pulleys were removed, 
when it was found that the reduction had been accomplished, although 
neither the patient nor his attendants had noticed the return of the bone 
to its socket. For several days there was entire loss of sensibility and 
motion in the leg, owing, probably, to the pressure which had been made 
upon the sciatic nerve ; but these symptoms gradually disappeared." 

Here, too, it is uncertain whether the injury to the nerve was caused 
by the pressure upon it of the head of the femur or by its elongation 
during reduction. 

Maclise 5 gives a plate of a dislocation of the femur backward in which 
the sciatic nerve is stretched over the neck of the bone ; and he says : 
" In general (in dislocations into the sciatic notch) the great sciatic nerve 
is bent over the femur and put on the stretch." . . "I have seen it 
so situated in regard to the head of the femur that the reduction could not 
possibly (?) have been effected with safety to that nerve." The plate 
apparently represents a dislocation produced upon the cadaver, and it 
seems probable that the text refers to dislocations similarly produced. I 
know of only one clinical case in which such relations of the parts have 
been observed : Quain's, Chap. XXV., Fig. 127. 

Fracture. — Fracture of the dislocated bone during reduction has occurred 
in dislocations of the shoulder, elbow, and hip, and not only when great 
force has been employed, but also during comparatively gentle manipu- 
lations to flex, abduct, or rotate the limb. 

At the shoulder the recorded cases appear all to have been dislocations 

1 Petit: Maladies des Os. Edition of 1844, p. 52. 

2 La Motte: Traite de Chirurgie, vol. iv. p. 343. 

3 Hutchinson: Med. Times and Gazette, 1866, i. p. 194. 

4 Hamilton: Fracts. and Disloc, 1880, p. 789. 

5 Maclise : Dislocations and Fractures : Plate 25, Fis. 2. 



92 ACCIDENTS IN REDUCTION OF DISLOCATIONS. 

of long standing in elderly people, and in most the accident was caused 
by forcible rotation during traction. Hamilton, 1 who had personal ex- 
perience of such, cases, found at the autopsy of one of them that the 
fracture was at the surgical neck, and thought it to be the same in the 
others. In Fano's case 2 the fracture was thought to be at the anatomical 
neck. In Richet's 3 the broken end of the shaft was brought into the 
glenoid cavity, with subsequent formation of a useful joint; and Agnew 4 
obtained a similar and highly satisfactory result, after fracture of the 
surgical neck of the humerus during attempted reduction, by keeping up 
constant movements until a false joint had formed between the fragments. 

Several authors assert that the ribs have been broken during reduction 
by the pressure of a firm axillary pad used as a fulcrum, and also say 
that the lip of the glenoid cavity may be broken during reduction. 

At the elbow fracture of the olecranon has been frequently caused, 
either intentionally or by accident, in the reduction of old dislocations. 
There is but one recorded case of its fracture in a recent dislocation, and 
even in this there is some doubt whether the fracture had not taken 
place before the reduction was attempted (Daugier, in Malgaigne, loc. 
cit., p. 146). 

Markoe 5 mentions a case, apparently unique, of fracture of the humerus 
in an attempt to reduce an old dislocation of the elbow. u While making- 
extension, and at the same time trying to flex the forearm on the arm, 
the humerus gave way, and a very oblique fracture was found to have 
occurred about a hand's breadth above the joint." 

In dislocations of the hip the femur has been broken, usually at the 
neck, but once at least at the lower end of the shaft ; and it is asserted 
by some that the rim of the acetabulum also has been broken. In a case 
reported by Malgaigne, a dislocation backward of eight months' standing 
in a patient seventeen years old, traction to the amount of nearly five 
hundred pounds was first used unsuccessfully ; it was then reduced to 
three hundred, and the limb slowly rotated outward ; a crack was heard, 
and it was found that the femur had been broken three finger-breadths 
above the condyles. In all the other cases the accident was due not to 
traction, but to efforts made by the hands of the surgeon to change the 
position of the limb, rotation or abduction. Although the force thus 
applied is slight compared with that developed by the use of pulleys, it 
must be remembered that its effect is greatly increased by the leverage of 
the limb. 

There is reason to believe that after long disuse a bone becomes weak, 
and this supposition is offered by Profs. Markoe and Bigelow in explana- 
tion of the accident in their cases. In that of the former the patient was 
forty-two years old, and the dislocation of seven weeks' standing ; in. that 
of the latter, twenty-three years old, and six months' standing. In the 
former the bone broke with a distinct snap ; in the latter with a continued 
fine crepitation during slow flexion of the limb. The final result in 
Bigelow's case was good; the head of the bone was firmly attached to 

1 Hamilton : Loc. cit., p. 660. 2 Marchand : Loc. cit., p. 82. 

3 Richet: Gaz. des Hopitaux, 1860, p. 159. 

4 Agnew : Surgery, vol. ii. p. 32. 5 Markoe : Dis. of the Bones, p. 18. 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 93 

the back of the trochanter, the shortening was one and a half inches, the 
limb was in good position and moved freely in all directions except that 
of eversion. In a case quoted by Sir Astley Cooper (loc. cit., p. 45) an 
equally good result was obtained. 

Inflammation, suppuration, gangrene. — The inflammatory reaction 
induced by a dislocation is usually moderate, and, as has been shown in 
Chapter III., rarely terminates in suppuration ; and when excessive 
reaction does follow the reduction of a recent dislocation, it is not always 
possible to determine whether the original traumatism or the reduction is 
responsible for it. In dislocations of long standing this difficulty does not 
exist, for the primary reaction has completely subsided, or, if persistent, 
has become moderate and chronic before the reduction is attempted, and 
its renewal or exacerbation is plainly due to its interference. 

The inflammation may be due to the direct pressure of the apparatus 
used for making extension, or to laceration of the parts about the affected 
joint ; the latter is the more dangerous because of the probability that 
the inflammation and suppuration may extend to the cavity of the joint, 
but the former also has proved fatal, as in the following case quoted by 
Marchand from a report by Velpeau. 1 A dislocation of the elbow of six 
weeks' standing, in an elderly man. Two unsuccessful attempts to 
reduce, at a week's interval, without accident. In the third attempt 
counter-extension was made by bands attached to the upper part of the 
arm and passing under the axilla, and traction was made by pulleys. 
On the fourth day a diffuse phlegmon appeared in the axilla and spread 
slowly over the lateral wall of the chest ; multiple incisions were made, 
erysipelas followed and terminated fatally in six days. 

Of the other form, laceration of the parts about the affected joint, the 
following case is an example. It was under the care of Malgaigne, is 
briefly referred to by him (loc. cit., p. 168), and is reported in full by 
Parmentier. 2 A man, thirty-four years old, with an intracoracoid dislo- 
cation of six months' standing. Three attempts to reduce were made, 
the traction in the last amounting to more than four hundred pounds, 
and the head of the bone being brought almost back to its place, but an 
attempt to force it into place by lateral traction with a bandage failed 
and even lacerated the skin on the posterior margin of the axilla. On 
the fifth day after the last attempt the patient complained of pain in the 
axilla, and the following day became delirious, and a large quantity of 
pus escaped through the laceration of the skin ; trismus and tetanus 
followed, and death two days later. 

The autopsy showed abscesses under and behind both pectoral muscles, 
in the substance of the coraco-brachialis and along its under surface, and 
communicating with the new articular cavity through a rent in its capsule. 
The head of the humerus was prevented from returning to the glenoid 
cavity by adhesions to the new capsule and shortening of portions of the 
old one. The glenoid cavit}^ had lost its cartilage and was overlaid with 
movable fibrous tissue having a serous surface, apparently the posterior 
portion of capsule drawn across it. 

1 Velpeau : Annales de la Chirurgie francaise et Etrangere, vol. i. p. '297. 

2 Parmentier: Bull, de la Soc. Anatomique, 1852, p. 302. 



94 ACCIDENTS IN KEDUCTION OF DISLOCATIONS. 

The following case, reported by Mr. Jonathan Hutchinson, 1 is even more 
striking. An elderly woman, drunk, was admitted with a dislocation 
into the axilla ; an attempt to reduce failed. The next day she said the 
shoulder had been dislocated for several years, but she was not believed, 
and reduction was again attempted with the aid of chloroform by moderate 
manual extension directly outward and the knee in the axilla as a ful- 
crum ; the attempt was continued for ten minutes. Great inflammation 
followed, the joint suppurated, and the patient died. The autopsy showed 
a new articular cavity formed beloAv and in front of the glenoid cavity. 
The soft tissues of the joint were wholly destroyed by suppuration, and 
every trace of cartilage removed. 

An experience of Broca's shows that an unfortunate, even fatal, result 
may follow an apparently judicious and moderate attempt at reduction. 

The patient, 2 a coachman, thirty-nine years old, entered the hospital 
for treatment six months after he had dislocated his left hip. Traction 
to the amount of more than five hundred pounds was made with Mathieu's 
apparatus without success, and the attempt was not repeated. No ill 
result appearing, the patient w T as discharged at the end of a week. A 
fortnight later he was admitted to another hospital with considerable 
swelling of the hip and peritonitis, and died on the following day. The 
autopsy showed a collection of pus occupying the old and new articular 
cavities, filling the external iliac fossa, infiltrating the gluteus medius, 
and in contact with the entire surface of the internal and external obtu- 
rators and with the obturator foramen ; also a generalized peritonitis, 
much more marked in the true pelvis than elsewhere. The course of the 
lesion was thought to have been : inflammation of the new joint, exten- 
sion to the old one, then to the obturator internus, and finally to the 
peritoneum. It was thought probable that the patient had resumed work 
immediately after leaving the hospital, and that this untimely use of the 
limb had provoked the suppuration. 

In a few recorded cases the inflammatory reaction was so severe that 
the limb, or the affected segment thereof, became gangrenous. Dupuy tren* 
reported a case in which, after reduction of a dislocation of the thumb by 
long and violent efforts, the thumb became gangrenous and separated at 
the metacarpophalangeal joint. 

These cases are to be distinguished from those in which gangrene has 
been caused by injury to the vessels or nerves, as in the case of La Motte 
referred to in the section on Injury to Nerves, and probably in Dela- 
garde's, 4 in which, after reduction of an old dislocation of the shoulder, 
abscesses and points of gangrene formed in the limb and rendered ampu- 
tation at the shoulder necessary. 

Persistent oedema of the limb, a condition resembling elephantiasis, 
has been observed in a few cases in which unsuccessful attempts had been 
made to reduce old dislocations, evidently the result of interference with 
the venous flow. In a case of Malgaigne's, quoted by Yelpeau, 5 the 

1 Hutchinson : Med. Times and Gazette, 1866, i. p. 304. 

2 Keported by Tillaux in Bull, de la Soc. de la Chir., 1868, vol. ix. p. 266. 

3 Quoted by Marchand, loc. cit., p. 129. 

4 Delasrarde: St. Barthol. Hosp. Bep. vol. iv. p. 89. 

5 Marchand: Loc. cit., p. 131." 



ACCIDENTS IN REDUCTION OF DISLOCATIONS. 95 

oedema of the arm disappeared simultaneously with the development of 
numerous varicose veins in the arm and shoulder. 

Syncope and sudden or early death; fat embolism. — Besides the 
numerous cases already quoted in this chapter which show the dangers 
to the life of the patient that may arise in the course of an attempt to 
reduce a recent or an old dislocation, there are still others which indicate 
that life may be seriously threatened, or even destroyed, by other acci- 
dents or complications than the rupture of important vessels or nerves or 
excessive reaction and suppuration. In some of the fatal cases the failure 
to make an autopsy leaves the cause of death obscure, but the symptoms 
point to rupture of a vessel as a possible cause. An example of this kind 
is the case of the mayor of Mines, operated on by Delpech' for a dislo- 
cation of the shoulder. Traction was made by ten assistants ; at the 
moment of reduction the patient grew pale, became unconscious, and 
immediately died. This syncope seems to have differed only in its result 
from that accompanying rupture of a vessel or nerve in some cases (e. g., 
Agnew, Sands, and Flaubert, quoted above). 

Quite recently E. Boeckel 2 has reported a case the autopsy of which 
suggests another explanation, not only of some of the deaths by syncope, 
but also of some attributed to the anaesthetic. 

The patient was a man fifty years of age, with a recent ilio-pubic dis- 
location, who was brought to the hospital after an unsuccessful attempt 
to reduce. Chloroform was given and reduction made in seven minutes ; 
the patient grew pale, his respiration weakened and promptly stopped. 
The autopsy showed the heart to be atrophied, both pulmonary arteries 
plugged by non-adherent clots, rounded like emboli, in the medium-sized 
branches and those of the third and fourth order, and also fat embolism 
of the lungs very wide-spread and intense. The iliac and femoral veins 
were free, but there was a thrombus in the popliteal vein from which it 
was thought those in the pulmonary arteries had been broken off. 

Before the use of anaesthetics, in the times when muscular resolution 
was sought to be obtained by measures which depressed and weakened 
the patient, and when the efforts to reduce were made with great violence 
and sometimes prolonged for hours, exhaustion of the patient habitually 
followed, and death was sometimes the consequence. Malgaigne refers 
briefly to several such cases and gives one in detail : an athletic man, 
forty years old, with an old dislocation of the humerus. After having 
made a free venesection, Lisfranc reduced the dislocation by traction on 
the fourth attempt. The patient returned unaided to his bed and seemed 
well, although pale; two hours later he called the nurse, said he felt ill, 
uttered a cry, and died. The autopsy showed the vessels, nerves, and 
spinal cord intact, the viscera in good condition, and only an excessive 
injection of the vessels of the pia mater and a serous effusion in its 
meshes. 

1 Malgaigne: Loc. cit , p. 152. 

2 Boeckel : Mort subite par embolies pulmonaires, simulant la mort par le chloro- 
form apres reduction d'une luxation de la cuisse. Eev. des Sciences Med., Oct. 15, 
1881, p. 637. 



$6 ACCIDENTS IN SEDUCTION OF DISLOCATIONS. 

Death by the action of an anaesthetic, especially chloroform, is thought 
•to occur in a larger proportion of cases of reduction of dislocation than 
in other operations, but no satisfactory explanation of the greater risk, if 
it actually exists, has been given. Of 134 cases of death by an anaes- 
thetic collected by Marchand, in 17 the operation was the reduction of a 
dislocation ; of these 11 were of the shoulder, 3 of the hip, and 1 each of 
the kne<e, .elbow, and thumb. 



PART II. 

NON-TRAUMATIC DISLOCATIONS. 



CHAPTEE IX 



Under the term non-traumatic may be included all dislocations which 
exist at birth {congenital), although it is claimed that some of them are 
due to violence inflicted upon the foetus in utero, or even during delivery, 
and those which appear subsequent to birth as the result of non-trau- 
matic changes in one or more of the constituent parts of the joint 
("spontaneous," "symptomatic," "inflammatory," "paralytic," "myo- 
pathic," "chronic," "tardy," "dislocation by distention," "by relaxa- 
tion," "by destruction," "by deformity"), and those which may be 
reproduced at will by the individual, "voluntary." 

The existence of dislocations (at least of the hip) in the newborn 
child, and their non-traumatic character, have been recognized since the 
earliest times, but the accurate study of the subject may be said to have 
begun in 1818, with Schreger, who examined, post-mortem, two speci- 
mens in a girl two and a half years old and a woman of forty-eight. A 
few years later, 18*26, Dupuytren brought the subject before the Academie 
des Sciences, and called attention especially to the facts that the affection 
was often inherited, and often bilateral. Since then the subject of con- 
genital dislocation of the hip has been actively studied by many, and the 
similar but much rarer affections of other joints have received due 
attention. 

Statistics. — Dislocations have been observed at birth in many joints, 
but not only do those of the hip far exceed all others in number, but the 
latter are actually, as well as relatively, so rare that their statistics have 
not much value. Next to that of the hip the most common dislocation 
is apparently of the shoulder, and then that of the head of the radius. 
Kronlein says that the records of Von Langenbeck's Polyclinic show 90 
congenital dislocations of the hip, 5 of the shoulder, 2 of the head of 
the radius, and 1 of the knee. It is not exceptional to find several dislo- 

1 The use of the term congenital to classify certain dislocations is objectionable for 
several reasons, which will appear in the course of the discussion of the subject. It 
includes forms that radically differ in their etiology and pathology, but as these forms 
cannot well be distinguished from. one another during life, a classification based 
upon other points cannot be realized in practice, but must be confined to the dead- 
house and museum. 



98 



CONGENITAL DISLOCATIONS. 



cations present in an individual, or one or more dislocations associated 
with such congenital defects as spina bifida, club-foot, ventral hernia, 
encephalocele, and exstrophy of the bladder. 

As will appear in studying the etiology of this affection, the statistics 
of congenital dislocation of the hip include cases widely different in their 
origin, and even some which are acquired and not congenital, that is, 
some which have been produced during the first few months of life, per- 
haps before the patient began to walk, by the unopposed action of certain 
groups of muscles after paralysis of others. It seems probable, however, 
that the error thus arising is not a large one, but still, for this and for 
other reasons, I shall here quote only the more recent statistics, believing 
them to be the most nearly correct. These are Drachmann's, 1 Pravaz's 
(quoted by Kronlein) and Kronlein's. 2 

Table VI. — Congenital Dislocations. 





Period. 


Cases. 


Male. 


Female. 


Single. 


? 


Double. 




Left. 


Right. 


Drachmann 

Pravaz .... 

Kronlein .... 


1865-1880 
1863-1878 
1875-1880 


77 
107 
SO 


10 
11 
14 


67 
96 
76 


24 
27 
32 


24 

29 
22 


5 


29 
51 
31 


Total 




274 


35 


239 


83 


75 


5 


111 









Prahl's, quoted above in Chapter I., are not given in sufficient detail 
to be included in the table; they comprise 18 cases; 3 were males, 15 
females, making with those in the table a total of 292, of which 38 were 
males, 13 per cent., and 254 females, 87 per cent. Angot 3 says that of 
about 20 cases observed by him at the Hopital des Enfants malades in 
1882, all were girls. Of 11 cases of congenital dislocation of the knee 
collected by Hibon, 4 7 were girls, 3 boys, and in 1 the sex was not 
recorded ; of these, 3, 1 girl and 2 boys, were stillborn, and presented 
other very marked deformities. 

According to a remark made by Broca in a discussion on this subject 
in the Societe de Ohirurgie, 5 Parise, while interne at the Hopital des 
Enfants trouves, dissected the hips of all the children that died there 
during his term of service, 332 in number, and found single and double 
dislocations in 3. This would indicate a far greater frequency of the 
affection than clinical records do. 

Etiology. — The discussion of this branch of the subject, which was 
taken up with much interest after the publication of Dupuytren's memoir, 
was not fruitful of positive results because of the lack of anatomical 
material and minute examination, and of the failure distinctly to dis- 



1 Drachmann : Schmidt's Jahrbuch, 1881, vol. clxl. p. 170. 
3 Kronlein: Deutsche Chirurgie, Lief. 26, p. 82. 

3 Angot: Luxations congenitales de'la hanche. These de Paris, 1883, p. 11. 

4 Hibon : Luxations congenitales du tibia en avant. These de Paris, 1881, p. 7. 

5 Broca: Bulletins de la Societe de Chirurgie, 1866, vol. vii. p. 331. 



CONGENITAL DISLOCATIONS. 99 

criminate between different forms and between the original bony defects 
and the changes produced by long use of the deformed limb. Since the 
affection is one w T hich often escapes recognition until the child begins 
to walk, it was sometimes confounded with dislocations resulting from 
infantile paralysis, and as it is one which does not destroy life, the 
opportunities for direct anatomical investigation w^ere almost entirely 
restricted to two .classes of cases, the stillborn and those that died shortly 
after birth in consequence of other important congenital defects, and 
those in which the original changes had been masked or supplemented by 
subsequent ones produced by the further displacement of the head of the 
femur and its abnormal relations to the adjoining parts. In the former, 
incorrect inferences were drawn from the associated defects, as when the 
irritation of an over-full urinary bladder, or the senaration of the sym- 
physis pubis, was deemed the immediate cause of the arrest of development 
of the acetabulum ; and in the latter the attention was led far astray by 
prominent changes in the bones. The history of the theories advanced 
has not only an historical value, but it serves also to indicate certain 
varieties and prominent features of the affection, and therefore I append 
the following resume made by Kronlein. It must be remembered that 
most of the theories deal exclusively with dislocations of the hip. 

1. The so-called congenital dislocation is traumatic, and arises : 

a, through external violence acting upon the foetus in utero, or through 

the action of the muscles of the foetus itself. Hippocrates and 
the early writers held that mechanical injuries of the belly of the 
mother could produce dislocation in the foetus. Cruveilhier did 
not entirely reject this theory in some cases. Chatelain, Kleeberg, 
Zielewicz, even specify in their three cases the injury, a fall in the 
seventh month, which, in their opinion, had caused the dislocation. 
Chaussier claims even that a dislocation can be caused by the 
contraction of the muscles of the foetus, and narrates in support 
the case of a young woman who, during the ninth month of 
pregnancy, felt on three occasions such violent movements of the 
child that she almost became unconscious. When delivery took 
place at term, the child had a complete dislocation of the left 
forearm. 

b, during delivery. 

Capuron (1834) held that some congenital dislocations of the hip 
had been produced during delivery, by traction with the finger on 
the groin in breech-presentations. Chelius and d'Outrepont ( 1 839) 
maintained even that none of the so-called congenital dislocations 
of the hip were congenital in the sense that they were due to a 
faulty development of the acetabulum, but that all were caused 
by traction on the foot during delivery. 

2. Congenital dislocation (of the hip) is a spontaneous dislocation, and 
is occasioned : 

a, by softening and laxity of the ligamentous portion of the joint 
(Sedillot, 1836). This opinion was held in part by Stromeyer 
(1840). 



100 CONGENITAL DISLOCATIONS. 

b, by foetal hydrarthrosis (Parise, 1842) or other joint affection, such 
as fungous synovitis with effusion (Verneuil and Broca), or caries 
and destruction of the capsule (Morel Lavallee, Albers, Von 
Amnion). 

3. Congenital dislocation (of the hip) is due to the peculiar position 
of the lower limbs of the foetus in utero. 

a, it is possible that in the strongly flexed position of the hip the 

pressure of the head of the femur upon the posterior or lower 
portions of the capsule may, when the latter is abnormally weak, 
cause dislocation (Dupuytren, 1826). 

b, congenital dislocation of the hip is due to abnormal adduction of 

the thigh in utero, to a compressed position of the foetus due to 
deficiency in the amount of the amniotic liquid (Roser, 1864). 

4. Congenital dislocation of the hip, like most congenital deformities 
of the joints, such as club-foot, wry neck, and spinal curvature, is the 
result of primary muscular contraction, which is itself to be regarded as 
the result of an affection of the central nervous system (J. Gruerin, 1840, 
and, following him, Chaussier, Melicher, Mercer-Adam, Carnochan, 
Erichsen, and others). 

5. Congenital dislocation of the hip is often only the last stage of a 
paralysis and consequent atrophy of the pelvi trochanteric muscles. 
This foetal paralysis leads gradually to relaxation of the ligaments, and 
this, often only after the lapse of time, and especially after the children 
have begun to walk, and by the action of the weight of the body, to dis- 
location (Verneuil, 1866). This theory has recently (1878) been brought 
forward again by some of Verneuil's pupils (Reclus, Dalby), and extended 
to congenital dislocations of the humerus (Kirmisson). 

(Kronlein in this fails accurately to define the position of the supporters 
of this theory. Their contention is not so much that congenital disloca- 
tions are thus produced, but rather that some so-called congenital disloca- 
tions originate after birth in a paralysis, and are mistakenly thought to 
have been congenital. Reclus 1 formulates his conclusions as follows : 

1. From the group of so-called congenital dislocations paralytic dislo- 
cations must henceforth be withdrawn. 

2. These dislocations follow " amyotrophies," and may appear at any 
age, although they have rarely been seen except in infancy. 

3. For their production two conditions are necessary — atrophy of a 
muscular group ; integrity of its antagonists. 

4. At the hip the iliac dislocation is the most common. It is due to 
the contraction of the adductors, which is unopposed because of the 
atrophy of the gluteal and pelvi-trochanteric muscles.) 

6. Congenital dislocation of the hip is due in most cases — and these 
should be regarded as typical — to a defect of formation or development, 
which prevents the joint from assuming the normal shape. This very 
generally held theory was presented by Palletta, and then taken up and 
specially developed by Schreger, Dupuytren, Breschet, Von Amnion, 
and others. 

Schreger emphasizes the fact that so-called congenital defects are not 

1 Revue Mensuelle Med. et Chir., 1878, p. 88. 



CONGENITAL DISLOCATIONS. 101 

produced by an abnormal change in preexisting, normally formed parts, 
but are due to defective formation or arrest of development, and that is 
especially true of congenital dislocations of the hip. Dupuytren and 
Breschet suggest a delayed development of the three pelvic bones forming 
the acetabulum. Since the vascular and nutritive supply of the pelvic 
organs and walls is independent of that of the lower limbs, it may 
happen, according to Breschet, that the growth of the pelvis is delayed, 
and fails to keep pace with that of the femora. The latter are then 
drawn back to the lowest point on the outer surface of the former, and 
rest in the external iliac fossa. Von Amnion, 1 in his remarkable work, 
expresses himself very clearly concerning congenital dislocations, which 
he terms dysarthroses congenita?. "Even if their external appearance," 
he says, " corresponds somewhat with that of dislocations acquired after 
birth, yet in their method of formation they differ essentially from them, 
and they also have only the slightest resemblance to those secondary 
dislocations that follow joint disease. ... In many cases there is in 
part the greatest certainty, and in part the greatest probability, that the 
affection depends upon an arrest of the constituent parts of the joint at 
an earlier foetal stage of development." And further (loc. cit., p. 3) : 
" If the term ' luxatio' is in general understood to mean the slipping of 
a movable bone out of its natural joint connections, it is applicable only 
with the greatest restrictions to the congenital dislocations in question. 
There are cases of so-called congenital dislocation in which the 
head of the bone has never left its corresponding joint surface — that is, 
has never been dislocated, but rather, on the contrary, has never been in 
normal and proper relations with it." According to Von Ammon, then, 
a congenital dislocation is an arrest of development. The acetabulum 
does not develop into the usual, symmetrically rounded, deep socket, but 
retains its earlier saucer-shape ; while the head of the femur, continuing 
to grow, becomes too large for the small acetabulum, and no longer suit- 
able to lodge in it. (Kronlein, loc. cit., p. 84.) 

Von Ammon recognized not only this typical form of congenital dislo- 
cation but also the other varieties that had been described by other 
authors, and quoted cases and reproduced drawings in illustration of 
them. So far as the typical form is concerned, but little less has been 
added since his time to our knowledge of its pathogeny, and that little 
is contained in a paper published by Grawitz 2 in 1878, who, by micro- 
scopical examination of twelve specimens of congenital dislocation in 
seven newborn children, showed that the arrest of development consisted 
in a failure of the Y cartilage of the acetabulum to carry on the growth 
of one or all of the three segments of the os innominatum. He found, 
in his first case, for example, the acetabulum only as large as that of a 
foetus of about the fifth month, and the Y cartilage broader than usual 
because of diminished ossification of the three adjoining bones, the pubis, 
ischium, and ilium (Fig. 9). The cartilage was hyaline and vascularized, 
and with normal, elongated cells containing one, two, or three nuclei. 

1 Von Ammon : Die angeborenen chirurgischen Krankheiten des Menschen, 1842, 
p. ix. 

2 Grawitz: Virchow's Arch., 1878, vol. 74, p. 1. 



102 



CONGENITAL DISLOCATIONS. 



On comparison with sections of a normal pelvis of the same size, a strik- 
ing difference appeared at the junction of the bone and cartilage. The 
formative zone in all three epiphyses was very imperfect, its cells scanty 
and widely separated, and the zone of cells arranged above one another 



Fig. 9. 





Section through the Y cartilage of the acetabulum into the obturator foramen. A, normal pelvis; 
J5, pelvis of child with congenital dislocation of the hip. (Grawitz.) 

in rows adjoining the line of ossification was not one-third as wide as it 
normally is, and the arrangement of its cells was irregular and broken. 
In two cases (Cases IV. and V.) the difference was even greater than in 
the first, for the zone of calcification was entirely lacking, and the carti- 
lage cells contained no nuclei but only fat granules. In some of the 
cases the Y cartilage was centrally interrupted by an interposed wedge of 
embryonal adipose tissue. On the other hand, the appearances in the 
femur were those of normal growth, except in one case. In no case was 
there premature ossification of the Y cartilage, such as had been alleged 
shortly before by Dollinger 1 in explanation of the same affection. 

The conclusion, I think, cannot be avoided that while in a limited 
number of cases dislocations existing at birth, especially in joints other 
than the hip, may have been caused by traumatism, abnormal position of 
the limb, or paralysis in the manner alleged by various writers, -yet in 
the great majority of congenital dislocations of the hip the cause is to be 
found exclusively in arrest of development of the acetabulum by deficient 
action or vitality of the cells of the Y cartilage. And to the testimony 
in support of this opinion furnished by anatomical examination of speci- 
mens may be added that drawn from clinical observation, such as the 
coexistence of other deformities due to arrest of development, the fre- 
quency of double and multiple dislocations, the inherited tendency to the 
affection, and its great predominance in females. 

Many of the congenital dislocations of other joints than the hip must 
also be regarded as due to defective formation of the corresponding bones, 
but the defect is rather a malformation apparently, than the result of an 
arrest of the development of one of the bones constituting the joint. At 
the elbow, however, in dislocation of the head of the radius, this bone is 
sometimes found relatively, and even actually, longer than the ulna, so 
that the dislocation may be in part the result of an arrest of the growth 
of the ulna. In a specimen taken from an adult, pictured by Humphrey 2 



1 Dollinger: Arch, fur klin. chirurgie, 1877, vol. 20, p. 622. 

2 Humphrey: Med. Chirurg. Trans., vol. 45, p. 296. 



CONGENITAL DISLOCATIONS. 103 

(Fig. 10), of dislocation of the head of the radius forward and upward, 
there was ankylosis of the joint between the ulna and humerus, and the 
lower third of the ulna of the other arm was lacking. 

Fig. 10. 




Congenital dislocation of the head of the radius upward and forward, with exaggerated growth in length. 

In some dislocations of the knee characterized by hyperextension of 
the leg upon the thigh the cause appears to have been muscular contrac- 
tion. 

Of the other etiological varieties that have been asserted to exist, one 
at least seems to have been proved by direct examination to exist, that 
in which the dislocation follows distention of the capsule and ligaments 
by dropsy of the joint during intrauterine life. 

Pathology. — The opportunities for studying the pathology of congeni- 
tal dislocations other than those of the hip have been so very rare, and 
the study of those that exist has been made so uncertain by the doubt- 
fulness of the diagnosis in some and the difficulty in distinguishing 
between primary and later changes in others, that but little can be posi- 
tively said concerning them. In studying specimens of dislocation of 
the hip it is necessary, as Gurlt pointed out, to distinguish between those 
obtained from very young children who have never walked, those from 
older children whose growth was not completed, and those from adults. 

Hip. — The common form is dislocation upon the dorsum of the ilium ; 
the only exceptions, and they are extremely rare, are upon the pubis and 
into the obturator foramen. 

In the newborn child with a dislocation the acetabulum is smaller and 
natter than normal, and is continuous by its flattened posterior border 
with another articular surface or new acetabulum lying above and behind 
the original one. Usually, too, the head of the femur is smaller than 
normal, although still too large for the acetabulum, and the neck short or 
almost absent (Fig. 12) ; sometimes the head and neck together have a 
conical, pointed form. The ligamentum teres is long and flattened, the 
capsule is complete and embraces both the old and the new acetabulum 
(Fig. 11). The microscopical changes have been described above. 

The mechanism of the alteration seems plain ; as the femur and its 
socket are originally developed out of one continuous strip of tissue they 
are at first in normal relations to each other, but as the development of the 
acetabulum goes on more slowly and imperfectly than that of the head of the 
femur the latter becomes relatively too large, and being no longer firmly 
held in place it is gradually drawn backward and upward by the continu- 
ous action of the attached muscles, the corresponding edge of the capsule 
is pressed away from the cotyloid border, and a new articular surface is 



104 



CONGENITAL DISLOCATIONS 



formed at the point where the head of the femur comes to rest. Mean- 
while, the defective development of the original acetabulum persists, and 
its variation from the normal is probably still further increased by the 
absence from it of the femur. The remaining bones and the muscles not 
being put to sufficient use to feel the effect of. the changed relations in 
the joint suffer no change unless involved in some associated defect of 
development. 



Fig. 11. 



Fig 12. 



Head 
Neck 




Head 



Troch. 




Left hip of an eight months foetus with double dislocation. 
(Grawitz.) 



The femur of the same, divided 
longitudinally. (Grawitz.) 



But as soon as the child begins to walk, this change in the relations of 
the bones and muscles to each other makes itself felt, and as the local 
developmental weakness persists, two factors are now at work to remove 
the condition of the parts still further from the normal. The acetabulum, 
by its continued failure to share equally in the growth of the pelvis, 
becomes relatively smaller and more deformed, the head of the femur is 
removed still further from it, and becomes deformed in consequence of 
its irregular bearings upon the surface of the ilium ; the ligamentum 
teres becomes longer, flatter, and thinner, and the capsule thick and 
strong, and its cavity commonly larger than usual. As the individual 
advances in life, and after puberty has been reached, the ascent of the 
femur is finally arrested, partly by the formation of a socket, and partly 
by the resistance of the capsule and the muscles. The elements of sup- 
port then resemble in a measure those sometimes found with ununited 
fracture of the neck of the femur, and the pelvis, instead of resting 
directly upon the femur, is suspended from it by the capsule, ligaments, 
some of the pelvi-trochanteric muscles, and even by the psoas-iliacus, the 



CONGENITAL DISLOCATIONS. 



105 



tendon of which, instead of passing downward, curves around the brim of 
the pelvis and passes upward, outward, and backward to the lesser 
trochanter, which is now at a higher level than the acetabulum or even 
than the horizontal branch of the pubis. 

The head of the femur may be separated from the ilium by the inter- 
posed capsule, so that the support is entirely by suspension, and there is 
no real joint, one in which bony surfaces covered with cartilage play upon 
each other ; or the upper and posterior attachment of the capsule may 
still be found above the head of the femur, upon an overgrowth of bone 
springing from the ilium and forming the upper part of a new socket, 
the remainder of which is constituted by the body of the ilium. The latter 
bone sometimes shows at this point an overgrowth of bone, and sometimes 
a depression with a corresponding thickening on the opposite, inner surface. 
In the former of these two last-named conditions, it seems probable that 
the capsule has been for a time interposed between the femur and the 
ilium, and has finally disappeared at this point under pressure, the irri- 
tation of which has caused the outgrowth of bone before its periosteum 
has in turn disappeared ; in the latter, it is probable that the attachment 
of the capsule has been pushed back step by step, leaving a bare surface 
of bone, which has worn away under the pressure of the femur, or by 

Fig. 13. 




Double congenital, subacromial dislocation. (R. W. Smith.) 

absorption ; while the associated irritation has led to a conservative 
thickening on its other side. The old acetabulum is narrow and elon- 
gated, running upward and backward ; the ligamentum teres perhaps 
destroyed by over-stretching. 



106 CONGENITAL DISLOCATIONS. 

The entire pelvis is also changed in shape by the abnormal direction 
of the pressure to which it is subjected in walking. If the dislocation 
is unilateral, the crest of the ilium on the corresponding side is carried 
inward, and the tuberosity of the ischium outw x ard, the horizontal branch 
of the pubis is elongated, and its direction from the symphysis is more 
upward and backward ; the anterior superior spine of the ilium is dis- 
placed inward and backward, and, in short, the entire bone undergoes a 
change in shape which carries its centre upward and backward, and 
makes its lateral surface more vertical. 

If the dislocation is double, the same changes are found on both sides, 
and the sacrum is more sharply curved. 

Congenital dislocation of the shoulder may be either subcoracoid, sub- 
acromial, or subspinous. R. W. Smith, 1 who was the first to describe 
them, gives examples and plates of the first two forms. He found the 
original glenoid cavity lacking or rudimentary, and the new one well 
developed either immediately under the coracoid process or on the outer 
side of the scapula below the acromion (Fig. 13). For a description of 
the cases see Chapter XVIII. 

At the elbow the head of the radius may be displaced upward along 
the anterior surface of the humerus, or backward, or inward so as partly 
to overlap the coronoid process of the ulna (Fig. 14). In a case of the 

Fig. 14. 





Congenital dislocation of the left elbow. (Mitscherlich.) 

latter kind, described by Mitscherlich, 2 the patient was a girl six years 
old, with a defect at each elbow, and a club-foot ; extension of the elbow 
was perfect, but flexion was limited on the right side to an angle of 
70 degrees, and on the left to one of 110 degrees. The specimen repre- 
sented in Fig. 20 was obtained by excision. 

Symptoms and diagnosis. — The symptoms of congenital dislocations 
differ very widely from those of the traumatic variety, and not only by 
the absence of symptoms peculiar to a traumatism, but also in the signs 
recognizable by palpation, and in the posture and mobility of the limb. 
In general terms, the dislocation is to be recognized by an examination 
which determines the abnormal position and altered shape of the corre- 
sponding ends of the bones and the range of motion, and by considera- 
tion of the history of the case. 

1 R. W. Smith : Dublin Med. Journ., 1839, vol. xv. p. 261. 

2 Mitscherlich: Arch. f. klin. Chirurgie, vol. vi. p. 218. 



CONGENITAL DISLOCATIONS 



107 



In dislocations of the hip the changes are very likely to pass unnoticed 
until after the child has begun to walk, because during this first period 
they are usually too slight to attract attention, and because an examina- 
tion for their detection is not likely to be made unless it is suggested by 
some special reason, such as coexisting malformations, or the history of 
similar defects in other members of the family. Even after the child 
has begun to walk, the defect may long remain unrecognized if both hips 
are affected, because the deformity of the regions and the shortening of 
the limbs being symmetrical, they do not attract much attention. Never- 
theless, the changes are so characteristic that when an examination is 
made the diagnosis cannot well remain in doubt. 

When the dislocation is unilateral and of the common dorsal variety, 
the patient limps because of the shortening of the affected limb ; and for 
the same reason the spine shows a lateral curvature, which can be removed 
by supporting the foot at the proper height. Because of the passage of 
the head of the femur backward and upward upon the ilium, the pelvis 
is tilted so that its upper portion is directed forward, and a marked 
anterior curvature of the lower portion of the spinal column is produced, 
which disappears when the patient is recumbent. 



Fig. 11 



Fig 16. 





Unilateral congenital dislocation of the kip. (Kronlein.) Double congenital dislocation of the hip. 



Inspection and manipulation reveal the ascent of the trochanter, and 
the head of the femur may sometimes be distinctly recognized. Kronlein 
recommends that it should be sought for by placing the patient upon the 
opposite side, and flexing and adducting the affected limb. The shorten- 
ing may be slight, moderate, or very great, and in the latter case can be 
diminished by traction upon the limb. In one case under my observa- 



108 CONGENITAL DISLOCATIONS. 

tion, a child less than two years old, the difference thus produced amounted 
to more than an inch. Usually the gluteal muscles and those of the 
thigh are less developed than those of the opposite limb. The move- 
ments of the joint are even more free than normal, except perhaps in 
abduction, but when voluntarily performed they are more or less lacking 
in precision and firmness. 

When the dislocation is bilateral, the patient walks, not with a limp, 
but with a peculiar characteristic waddle, which sometimes amounts to 
a double limp and makes progression difficult and uncertain. The upper 
part of the pelvis is sharply inclined forward, producing the same ante- 
rior curvature of the lower portion of the spine that is found in unilateral 
dislocation, but without the lateral curvature unless there is a difference 
in the amount of the defect on the two sides. The arms appear unusually 
long, and are sometimes exceptionally muscular. The local changes have 
been described above. 

At other joints, such as the shoulder, elbow, and knee, the position of 
the bones and the changes in their shape can be more easily made out, 
and the interference with the functions of the part, so far as it depends 
upon the relations of the bones to each other, appears usually to be less 
important than at the hip. A prominent exception to this is presented 
by one of the varieties of dislocation at the knee, dislocation forward, 
with extreme hyper-extension, so that the leg rests against the anterior 
surface of the thigh. This dislocation, which is due to contraction of 
the quadriceps extensor cruris, can be readily overcome by straightening 
the limb with the hands, and maintaining it in the proper position for a 
week or two, after which no further tendency to reproduction of the dis- 
location is manifested. Hibon 1 collected eight cases of this kind, three 
of which were reported to the Societe de Chirurgie in 1880. 

The prognosis in all dislocations, except that last mentioned, is un- 
favorable, so far as reduction is concerned. In many of them, the inter- 
ference with the use of the limb is slight ; in others this interference may 
be diminished by treatment. 

Treatment. — The treatment of congenital dislocation of the hip may 
aim at either of two ends — to reduce the dislocation, or to diminish the 
functional disability caused by it. The pathological and etiological 
details above given show how slight is the chance of attaining the first 
of these ends. The developmental variations from the normal structure 
of the head of the femur and of the acetabulum are commonly such that 
even if the two parts should be brought properly together, it would be 
highly improbable that the tendency again to separate when the limb 
was used could be successfully opposed. A radical, complete cure by 
reduction is, therefore, not to be expected, except perhaps in those rare 
cases in which the development of the parts has been regular, and in 
which the dislocation has been produced by one of the exceptional causes, 
such as traumatism, hydrarthrosis, a faulty position of the limb during 
intrauterine life or paralysis; and even in such cases it can only be ex- 
pected if the remedy is applied soon after the birth of the child, before 
changes have occurred to make reduction impossible. 

1 Hibon : Luxations congenitales du tibia en avant, These de Paris, 1881. 



CONGENITAL DISLOCATIONS. 109 

Nevertheless, even in cases characterized by defective development, 
much can be gained by treatment begun at an early age, and faithfully 
carried out. Many cures of such cases have been claimed, especially by 
the two Pravaz, father and son, the former of whom claimed to have been 
the first to realize this result in practice. He claimed even more, that he 
had effected reduction, and he read an elaborate paper before the 
Academy of Medicine in 1838, l explaining his method of treatment 
and supported his claims by the presentation of one patient and the report 
of three additional cases. The committee to whom the paper was re- 
ferred made a favorable report, and although the completeness of the 
reduction was disputed, the great amelioration of the patient's condition 
was established beyond question. Kronlein says that Pravaz subse- 
quently reported to the same body seventeen cases, in fourteen of which 
he claimed to have effected complete reduction by means of prolonged 
traction. In a report made by a committee of the Societe de Chirurgie 2 
upon a case shown to the Society by Pravaz, Jr., in which the same 
treatment had been pursued for two years, the completeness of the re- 
duction was denied, because the head of the femur could be distinctly 
felt behind the trochanter when the thigh was flexed ; but it was ad- 
mitted that the functions of the limb had been greatly benefited. 

Quite recently, Dr. Buckminster Brown 3 has reported a remarkable 
success obtained by him by continuous traction and fixation maintained 
with great care and patience for thirteen months, in a case of double dis- 
location in a girl five years old. So far as can be judged from the 
accompanying photographs, the restoration of form was complete, and 
the walk had become normal. The original report should be consulted 
for the details. It seems probable that in such cases a new socket forms 
at the site of the acetabulum. 

When the object has been to diminish the functional disability caused by 
the dislocation, it has commonly been sought by bringing the head of the 
femur as near as possible to the acetabulum, and retaining it there by arti- 
ficial means until it has fixed itself in this position. Continuous traction by 
weight and pulley, or by the splints used in the treatment of hip-joint dis- 
ease, is employed in old cases to bring the bone into position, and its reten- 
tion has been sought by the same means, and by fixed plaster-of-Paris 
dressings, or specially constructed girdles and bands. Barwell 4 thinks 
time can be saved in this treatment by subcutaneous division of the 
muscles that have been shortened, the adductors, rectus, and glutei. In 
very young cases benefit has been got by fixing the limb for a long time 
in the abducted position. Konig 5 recommends a felt corset which shall 
include the pelvis, and, by preventing it from tilting, effectually oppose the 
displacement of the femur upward and backward. He says older chil- 
dren and adults have been well satisfied with the functional results thus 
obtained. Landerer 6 describes a corset which can be cheaply made of 

1 Bulletin de l'Acad. de Med., Paris, vol. 3, p. 408. 

2 Bulletin de la Soc. de Chirurgie, 1864, p. 218. 

3 Brown : Boston Med. and Surg. Journal, June 4, 1885. 
* Barwell : British Medical Journal, May 28, 1887. 

5 Lehrbuch der Speciellen Chirurgie, 1881, vol. iii. p. 287. 

6 Landerer: Archiv fur klin. Chirur., 1885, vol. xxxii. p. 519. 



110 CONGENITAL DISLOCATIONS. 

alternate layers of bandages wet with silicate of soda and plaster of Paris, 
which is very durable, and has yielded excellent results. After it has 
been worn for some time, a year or more, the bone remains in place. 

Of late years excision of the head of the femur has been done in old 
cases. Kronlein mentions a case by Roser, in 1874, and Heusner 1 
reports a successful result in a girl twenty years old. In the latter case 
the dislocation was bilateral, and gave no special trouble until the age of 
seventeen, when the left hip became painful, and gradually grew so much 
worse that relief was sought in the hospital. The deformed head of the 
femur was removed, and the upper end of the femur fixed against the 
acetabulum, after the latter had been made deeper by chiselling. 

Margary, 2 of Turin, reported at the Congress at Copenhagen, in 1884, 
a case in which he had deepened the cotyloid cavity by chiselling, replaced 
the head of the femur in it, and had made a new capsule out of portions 
of the old one and of the periosteum of the ilium. The patient died of 
pyaemia. According to Da Paoli, 3 Margary abandoned the method in 
favor of excision of the head. Paoli thought the results of the latter so 
defective that he again tried arthrotomy, with the addition of measures 
designed to increase the local reaction and thus favor a better develop- 
ment of a new acetabulum. He deepened the cotyloid cavity by 
chiselling, and diminished the size of the head, and fastened the latter in 
place by driving a nail from the outer aspect of the trochanter through 
the neck and head into the acetabulum, and left it in place twenty-five 
days. The operation was followed by fever and suppuration, but the 
patient recovered, and the shortening of nine and a half centimetres was 
permanently overcome. He thinks the most suitable age is between the 
eighth and twelfth years. 

Congenital dislocations of other joints, except the knee, have rarely 
received any treatment. Malgaigne 4 mentions a case of infraspinous 
dislocation of the shoulder in a girl sixteen years old, treated by Gaillard 
by traction ; the head of the humerus was brought to the glenoid cavity 
and finally, after two recurrences of the displacement, retained there. 

In a case quoted above, Mitscherlich excised the elbow for the relief 
of the disability consequent upon a congenital dislocation of the upper 
end of the radius. 

In dislocations of the tibia forward, with extreme hyper-extension of 
the knee, a complete cure has several times been effected by forcible 
straightening of the limb and retention for a short time by splints. 

1 Heusner: Centralblatt fur Chirurgie, 1884, p. 751. 

2 Margary : quoted in Diet. Encyclopedique des Sciences Med., art. Hanche, p. 219. 

3 Da Paoli : Centralblatt f. Chirur., 1887, p. 336, 

4 Malgaigne : Des Luxations, p. 569. 



CHAPTEE X. 



SPONTANEOUS DISLOCATIONS. 



These are dislocations which have occurred without the introduction 
of a recognizable traumatism. It is generally held that some of the 
constituent parts of the joint must have previously been so altered by 
disease as to facilitate the occurrence ; but while this preliminary change 
does doubtless occur in the great majority of cases, yet there is reason to 
think that spontaneous dislocation may take place without it, through the 
continuous action of the muscles, when the limb has been long kept in a 
favorable position. Roser 1 says he has seen, in three cases, spontaneous 
dislocation of the hip produced by the reflex muscular contractions 
excited by pressure on the anterior portion of the spinal cord in patients 
affected with kyphosis and consequent paralysis. The dislocations 
occurred slowly, without pain or swelling of the region, and without a 
sign of coxitis. 

The term "spontaneous," although not entirely free from objection, is 
in general use, and is usually preferred to the others that have been pro- 
posed, such as pathological, symptomatic, inflammatory, and consecutive 
or secondary. Yolkmann 2 has classified them according to the primary 
changes which precede and facilitate their occurrence, as dislocations, 1st, 
by distention : 2d, by destruction ; 3d, by deformity ; including in the 
first those cases in which the joint has become loose through distention of 
its capsule and ligaments by an effusion within it, as in the eruptive 
fevers, rheumatic fever, pyaemia, and the puerperal state ; in the second 
those in which the shape of the articular end of the bone has been 
changed by caries, as in hip-joint disease ; and in the third those in 
which the shape has been changed by non-suppurative disease, as in 
arthritis deformans. To these may be added a 4th class, seen mainly 
in adolescents, in which the shape or growth of the bones has been so 
modified by the effects of pressure, muscular effort, or gravity that a 
permanent displacement takes place; and a 5th, "paralytic" or "myo- 
pathic," in which the dislocation is made possible by paralysis of some or 
all of the articular muscles, and is somtimes effected by the contraction 
of those which have not been paralyzed. 

Although the propriety of applying the term dislocation to a change 
in the relations of two bones whose corresponding articular portions have 
already been destroyed has been questioned, and although the change of 
place does not come within the definition of dislocation previously given, 
and although the condition has but little in common with traumatic 
dislocations, either in symptoms or in treatment, yet the term has been 

1 Roser : Centralblatt f. Chirurgie, 1885, p. 569. 

2 Yolkmann : Pitha and Billroth's Chirurgie, vol. ii. part 2, p. 658. 



112 SPONTANEOUS DISLOCATIONS, 

almost universally accepted and retained in preference to the proposed 
substitutes. 

In all these varieties the immediate cause of the dislocation is the 
action of gravity or muscular contraction. 

Dislocations by distention (Volkmann). — Concerning the pathology of 
this class but little is known by direct examination, because of the lack 
of autopsies, but the clinical history is well established. The joint by 
far the most frequently involved is the hip ; a few cases have been 
observed at the shoulder and knee. In the most common form the course 
of the symptoms is as follows i 1 A patient is attacked by febrile articular 
rheumatism or acute mono-articular arthritis ; the pain is great, the limb 
assumes a faulty position ; after a few days the pain suddenly ceases, and 
on examination the region of the affected joint is found to present a 
deformity similar to that which characterizes a traumatic dislocation. If 
the condition is left without treatment, the inflammation comes to an 
end without leaving either osteitis or suppuration, but with persisting 
deformity ; if, on the other hand, the dislocation is reduced, the 
deformity is thereby entirely removed, and in time complete recovery is 
obtained. 

In other cases the dislocation takes place in the course of some of the 
eruptive fevers or other febrile condition, sometimes without previous 
notable pain in the joint and without the knowledge, at the time, of the 
patient. William Keen 2 collected forty-three cases of arthritis occurring 
as a complication of typhoid fever, in thirty of which dislocation took 
place, twenty-seven times at the hip, twice at the shoulder, and once at 
the knee. 

It thus appears that these dislocations resemble those that are traumatic 
by their sudden occurrence, the absence of any lesion of the bones, and 
the possibility of immediate and permanent reduction with complete 
restoration of function. 

The following cases taken from Verneuil's paper will show the details. 

Obs. II. (loc. cit., p. 783). A young and healthy woman was attacked 
in 1845 by acute articular rheumatism after exposure to cold ; the pain 
was severe, especially in the right hip, but she was at first able to walk, 
although with a marked limp. At the end of the second week the pain 
in the hip suddenly ceased almost entirely, and recovery was thought to 
be at hand. A few days later she left the bed, but limped so badly that 
she could scarcely take a step without crutches. Some time later Verneuil 
was led to examine the hip, and was astonished to find marked deformity 
of the region with displacement of the head of the femur. The disloca- 
tion was not reduced, and when the patient was last examined, ten years 
later, the head of the femur could be still more distinctly felt in the 
external iliac fossa thinly covered by the atrophied gluteal muscles. 

Obs. I. (loc. cit., p. 782). A healthy girl, ten years old, had typhoid fever 
in July, 1883. During convalescence an attack of generalized rheumatism 
(or pseudo-rheumatism) occurred, ultimately localizing itself in the left 
foot and hip, with great pain, high fever, and considerable swelling of 

1 Verneuil, in Bull, de la Soc. de Chirurgie, 1883, p. 781. 

2 Keen: Toner Lectures, Smithsonian Institute, April, 1875. 



SPONTANEOUS DISLOCATIONS. 113 

the affected joints; very faulty attitude of the limbs and pelvis. On the 
11th or 12th day the pains suddenly ceased, and the child, which until 
that time had remained lying on the right side with the body and all the 
joints of the lower limbs flexed, was able to sit up in bed and allowed 
an examination. This examination revealed considerable shortening of 
the left lower extremity. Verneuil, called in consultation, easily recog- 
nized a dislocation of the femur upon the dorsum of the ilium. On the 
6th day after that in which the dislocation was presumed to have occurred, 
chloroform was given, the diagnosis confirmed, reduction easily made, 
and the child placed in a Bonnet gutter. At the end of another fortnight 
all swelling and sensitiveness had disappeared, and a complete recovery 
was effected. 

Obs. VIII. (loc. cit., p. 787). A healthy young girl was attacked by 
very acute, generalized, articular rheumatism ; both knees were affected, 
the left more than the right. Since flexion of the leg upon the thigh 
was the attitude that gave most relief, it was maintained by means of a 
large cushion placed transversely under the leg. One morning marked 
deformity of one of the knees was noticed, consisting in a subluxation 
characterized by considerable prominence of the femoral condyles and 
patella, and displacement of the head of the tibia upward and backward. 
There was also flexion of the joint at a right angle, marked tumefaction, 
great sensitiveness to pressure, tension of the skin, etc. The other knee 
was a little swollen and contained some liquid, but had preserved its form. 

The patient declared that the displacement occurred suddenly during 
the preceding night, after a sudden start and energetic muscular contrac- 
tion. 

Verneuil recognized the tension of the flexor muscles, which contracted 
sharply at the slightest attempt to straighten the limb. He gave chloro- 
form and easily reduced the displacement, noticing at the same time that 
all the femoro-tibial ligaments were very notably relaxed. The limb was 
placed in a splint in a position of almost complete extension, and after- 
ward in an immovable dressing. The patient left the hospital cured of the 
rheumatism but walking with hesitation because of the weakness of the 
limb, although the knee had regained its natural size and shape. 

The presence of a large effusion in the joint and the elongation of the 
ligaments have been assumed by all observers, and the actual presence of 
an effusion of some amount has been demonstrated in some of the excep- 
tional cases, knee and shoulder, where such demonstration was possible. 
On the supposition of this effusion and of the relaxation of the ligaments 
produced by it, the production of the dislocation has been explained. 
Verneuil has further called attention especially to the unopposed contrac- 
tion of certain muscles as the immediate cause. Some post-mortem 
observations have shown great distention of the capsule of the hip-joint 
in some cases (six ounces in Lerinser's case 1 ), and great elongation of the 
ligamentum teres in others (Stanley, 2 Hutton), but the latter may well 
have been the effect of the dislocation rather than its cause, and it does 

1 Quoted by Volkmann, loc. cit. 

2 Stanley : Med. Chirurg. Trans., vol. 24, p. 123. 



114 SPONTANEOUS DISLOCATIONS. 

not appear in the histories that the dislocations occurred in the manner 
now in question. Theoretically speaking, a rapid effusion within the 
joint should serve rather to hold the bones more firmly together by making 
the capsule tense, unless the latter is loose enough to circumscribe a 
sphere whose diameter is greater than the distance between the fixed 
points of the capsule on the two bones, and it does not appear that this 
is the case in all positions of the hip-joint. Relaxation of the capsule 
and ligaments would then, on this theory, be a necessary preliminary to 
the dislocation. 

Bonnet and Parise showed that by forcible injection of liquid into the 
cavity of the hip the articular surfaces could be separated for a distance 
of from three to six millimetres, one-eighth to one-quarter inch. The 
details of these experiments are not before me, but it seems probable that 
the separation existed only when the limb was flexed and the Y ligament 
thereby relaxed, for, according to Tillaux, 1 who repeated Parise's experi- 
ments, the injection causes the limb to become flexed. The flexed posi- 
tion relaxes the Y ligament, and if the capsule is filled with liquid the 
head of the femur can leave the cotyloid cavity without creating a 
vacuum, for the liquid takes its place, and thus a great obstacle to dislo- 
cation, atmospheric pressure, is removed. If it is remembered that these 
dislocations are always backward upon the dorsum of the ilium, and are 
preceded by the long maintenance of the limb in the position of flexion, 
adduction, and inward rotation which so greatly favors the occurrence of 
this dislocation, and that the muscles are stimulated to contraction by the 
pain of the arthritis, it does not appear improbable that this contraction 
is not only the immediate but also the preponderant cause of the accident, 
and that the arthritis favors it not by overstretching the ligaments but 
only by supplying an amount of liquid that removes the obstacle created 
by atmospheric pressure. These two conditions, pain and effusion, would 
explain why the dislocation does not also occur in the course of adynamic 
diseases in which the limb often remains for a long time in the flexed 
position. 

Certainly the theory of the production of the dislocation by simple 
overdistention is incompatible with the easy reduction and maintenance 
of the reduction noted in several cases. It was unfortunate for some of 
the patients that their surgeons held to this theory, and were logical 
enough to refrain from attempting reduction and to leave the patients 
permanently crippled. 

A few cases have been observed in which an acute purulent arthritis 
has been followed by dislocation ; but in such cases it is always possible 
that the capsule has been in part destroyed by the suppuration. 

Paralytic or "myopathic" dislocations, which are included by Kron- 
lein in the preceding class, are observed especially at the shoulder. 
The humerus is held up and kept in contact with the glenoid cavity by 
the tonicity of the attached muscles, and when this tonicity fails the 
weight of the limb causes separation of the bones and subluxation or 
complete dislocation. The cavity of the joint, thus enlarged, is filled by 

1 Tillaux : Anatomie topographique, p. 1082. 



SPONTANEOUS DISLOCATIONS. 115 

an effusion, but this effusion is the consequence of the separation rather 
than a favoring, precedent, and causative condition, for it is presumably 
drawn from the surrounding tissues by suction, just as oedema appears 
under a dry cup. 

At the hip they are produced by the unopposed contraction to those 
muscles which have not been paralyzed. In Roser's three cases of spinal 
caries, mentioned above, the dislocation was dorsal, and the immediate 
cause was the contraction of the adductors no longer opposed by the per- 
trochanteric muscles. The opposite form, dislocation upon the pubis, due 
to paralysis of the adductors and the consequently unopposed contraction 
of the muscles on the outer side and back of the hip, has been reported 
by Bradford 1 and Reclus. 2 

Another variety may be mentioned, in which by the unequal growth 
of parallel bones, the tibia and fibula or the radius and ulna, one of them 
is slowly dislocated. 

Voluntary dislocations, those which the individual can produce and 
reduce at will, may be mentioned in connection with this class. Those 
in which the peculiarity has originated in a previous traumatic dislocation 
are due to rupture of some of the ligaments or attached muscles and have 
been described among the consequences of traumatic dislocations ; but a 
number of cases have been recorded in which this cause could not be 
invoked in explanation. (See Chapter II.) The only case I have seen 
was a man about thirty years of age who, a few years ago, frequented 
the medical schools of New York and added to his income by exhibiting 
his peculiar power before the classes. 

Dislocations by destruction and Dislocations by deformity are of less 
practical interest to the surgeon because less amenable to treatment, and 
are to be regarded rather as incidents in, or symptoms of, other diseases 
than as morbid entities. 

In the former, dislocations by destruction, Yolkmann included those 
dislocations which occur in the course of chronic fungous or carious dis- 
ease of joints or as a consequence of acute traumatic suppurative arthritis. 
Frequent examples are seen at the hip and knee. 

In consequence of the destruction of the articular ligaments or of the 
bones themselves an abnormal mobility is created which allows the bones 
readily to be displaced by the action of gravity or by muscular contrac- 
tion. At the hip this displacement is usually upward and backward ; at 
the knee the well-known subluxation of the tibia backward or upward is 
produced by the contraction of the hamstring muscles, or, if the patient 
lies long upon one side and the destruction is well advanced, the displace- 
ment may be lateral to the distance of an inch or even more. 

In the latter, dislocations by deformity, Yolkmann included the dislo- 
cations which occur in the course of such affections as the morbus coxoe 
senilis and in the arthropathies of nervous origin, " Charcot's disease," 
in which the articular ends of the bones disappear by absorption without 
suppuration. 

The remaining form has been specially studied, so far as I know, only 

1 Bradford : Boston Med. and Surg. Journal, 1883, vol. 108, p. 73. 

2 Reclus : Eevue de Med. et de chir., 1878, p. 176. 



116 SPONTANEOUS DISLOCATIONS. 

by Madelung, 1 and only at the wrist ; the dislocation was always of the 
carpus forward, and was accompanied by marked changes in the shape 
of the radius of the bones of the first row of the carpus. The cause ap- 
peared to be overexertion, or, rather, prolonged and frequently repeated 
exertion in patients who, presumably, were predisposed to the change by 
defective vitality of the bones. Volkmann includes such cases under the 
general head of disturbances of growth of joints, loc. cit., p. 692. 

1 Madelung: Deutsche Gesellschaft fur Chirurgie, 1878, p. 259, and Arch, furklin. 
chir., vol. 23. 



PART III. 

SPECIAL DISLOCATIONS. 



CHAPTEE XI 



DISLOCATIONS OF THE LOWER JAW. 



Dislocations of the lower jaw are infrequent, constituting about four 
per cent, of all dislocations, according to Table III., Chapter I. They 
may be bilateral or unilateral, the former being the more common, in 
the proportion of about 5 to 2 according to Malgaigne, who found 54 
bilateral in a total of 76 cases which he collected. Of these 54, 31 were 
in women, and this greater frequency in the female sex is universally 
recognized. The injury is rare in infancy and old age because, it is 
thought, the rami of the bone are not so nearly at right angles with its 
body as in adult life. It has been observed in patients eighteen and 
seventy-two years old, and has been caused in the newborn child by 
obstetric manipulations. 

In the great majority of cases the dislocation is forward, the condyle 
of the jaw passing in front of the articular eminence at the root of the 
zygoma. A few instances have been reported of double or single dislo- 
cation backward with fracture of the wall separating the articular cavity 
from the external auditory meatus, of dislocation upward into the cavity 
of the cranium, and of unilateral dislocation outward with, or perhaps 
without, fracture of the body of the jaw. These are, however, entirely 
exceptional and may be briefly described before proceeding to the con- 
sideration of the common form. 

Dislocation backward with fracture of the posterior wall of the articu- 
lar cavity is caused by great violence received upon the chin and acting 
from before backward. One or both condyles may be driven through the 
wall into the external auditorv canal, breaking the bone and lacerating 
or pushing backward the outer cartilaginous portion. The production 
of the lesion is probably easier when the molar teeth are lacking from the 
upper or lower jaw, or if the mouth is partly open when the blow is 
received. The symptoms are pain in, and bleeding from, the ear, immo- 
bility of the jaw, the mouth being held partly open, and displacement 
backward, as shown by the relations of the front teeth to each other. 
The absence of the condyle from its normal position can be recognized 
by the touch, and the auditory canal is seen to be obstructed by the dis- 
placement of its anterior wall. 



118 DISLOCATIONS OF THE LOWER JAW. 

A case described by Croker King 1 as one of dislocation backward and 
outward of one condyle was probably such as above described. The 
patient was a boy eight years old, the lower incisor teeth were one inch 
behind the upper, the left lower molars just outside the upper ones, and 
the chin deviated to the left. The reporter accounts for the supposed 
unilateral dislocation on the left side by the springiness of the jaw in the 
median line, but as this springiness was not detected until after he had 
inferred that some such condition ought to exist to explain the production 
of the dislocation, as no mention is made of recognition of the position 
of the condyle, and as the boy bled from the ear immediately after the 
accident, it seems probable that the dislocation was backward through at 
least the outer part of the auditory canal. 

Le Fevre 2 reported an interesting and very exceptional case in which 
the injury was caused by a fall from the second story of a building, the 
blow being received upon the chin. The jaw was displaced slightly 
backward and to the left, the teeth were close together, and the mouth 
could not be opened. Slight bleeding from the left ear. The diagnosis 
of fracture of the condyle was made. The patient was dismissed in the 
fourth week still experiencing difficulty in mastication and deglutition. 
Subsequently he suffered from violent headache, had several attacks of 
convulsions, and died about six months after the receipt of the injury. 
The autopsy showed that the roof of the glenoid cavity had been frac- 
tured, the condyle had passed into the cranium between the fragments, 
the neck of the condyle was in part destroyed, the dura mater was exten- 
sively inflamed and thickened, and there was a large abscess in the middle 
lobe of the brain. 

Robert 3 received at the hopital Beaujon a patient who had been injured 
by the passage of the wheel of a cart across the right side of his face. 
The chin was deviated to the right, and the mouth was held open. The 
left condyle of the lower jaw could be distinctly felt under the skin 
above the root of the zygoma. Greatly surprised at this displacement 
Robert sought for and found a vertical fracture of the body of the bone 
on the right side just in front of the ramus. The left coracoid process 
remained under the temporal fossa, the sigmoid notch crossing and 
embracing the zygoma. Reduction was made by pressing the left ramus 
outward until the condyle was freed from its contact with the upper sur- 
face of the zygoma, and then drawing it downward and inward to its 
place. 

Neis 4 had an opportunity to observe a case in which the left condyle 
was dislocated in the same manner upward and outward, but apparently 
without fracture either of the jaw or of the temporal bone. The patient 
was a lad sixteen years old who received the injury by having his head 
caught between two boats, the pressure being upon the chin and occiput. 
The lower teeth were displaced backward, the mouth could not be opened, 
and there was slight oozing of blood from the left ear. Thirteen days 

1 King: Monthly Journal of Medicine, 1855, p. 265. 

2 Le Fevre: Journal Hebdornadaire, 1834, vol. 3, p. 333. 

3 Robert : Archives generales de Med. 1845, vol. 7, p. 44. 

4 Neis : Luxation du Maxillaire inf. en haut ou dans la fosse temporale. These 
de Paris, 1879, No. 252. 



DISLOCATIONS OF THE LOWER JAW. 119 

after the accident, when he first came under observation, he was still 
unable to open the mouth or take solid food. The lower incisor teeth 
were nearly half an inch behind the upper ones, the jaws could be only 
slightly separated and could not be brought entirely together. The left 
condyle could be seen and felt above and in front of the auditory canal 
in the temporal fossa; it moved with the jaw; there was slight deafness 
on that side, and a small blood-clot in the canal. No fracture could be 
found. Reduction was effected with difficulty under chloroform by forcing 
wooden wedges between the molars. Neis thought the dislocation could 
be accounted for by the peculiar shape of the face and jaw, the face 
being short and broad, the chin flat, and the rami of the jaw very diver- 
gent upward. 

Several other interesting cases are quoted in Neis's thesis. 

Dislocation of the jaw forward, the common form, is usually caused 
by muscular action, as in laughing, scolding, yawning, or vomiting, or 
exceptionally by violence in widely opening the mouth to introduce some 
large object, such as an apple or the fist, or in drawing a tooth, or by a 
blow upon the jaw. Morris 1 reported a case in which dislocation took 
place during sleep, the patient being a girl fifteen years old who had 
long had the habit of sucking her thumb. 

In order to understand this mechanism it is necessary to recall the 
construction and normal action of the joint. The lower jaw is attached 
to the skull by a synovial capsule which is strong on its outer side (the 
external lateral ligament), by an internal lateral ligament not in imme- 
diate relations with the joint but extending from the spinous process of 
the sphenoid bone to the margin of the inferior dental foramen, and by 
the stylo-maxillary ligament, a strong band extending from the styloid 
process of the temporal bone to the posterior border of the ramus of the 
jaw. The joint is occupied by an interarticular cartilage or meniscus 
which overlies the upper surface of the condyle and accompanies it in its 
normal movement forward from the glenoid cavity to the eminentia 
articularis when the mouth is opened. In front of the point to which 
the condyle thus moves forward the surface of the eminentia articularis is 
inclined slightly upward to become continuous with the much narrower 
under surface of the zygoma. The fibres of the muscles attached to the 
ramus which close the mouth run upward and forward, and only those 
belonging to the deep posterior portion of the masseter are vertical or 
inclined backward. 

Since the condyle moves forward when the chin descends, the centre 
of motion of the jaw is not in the condyle, but at a point below it at or 
near the dental foramen, and as the angle of the jaw is at the same time 
moved backward the axis of the ramus changes its relations to the direc- 
tion of the fibres of the masseter much more than it would if the centre 
of motion was in the joint, and it may become so far inclined forward 
that the posterior fibres of this muscle lie behind it in such a position 
that their contraction would tend still further to raise the angle of the 
jaw and thrust the condyle forward, thus exaggerating the effect of the 
action of the external pterygoid, which is to draw the condyle forward 

1 Morris: British Medical Journal, 1872, II., p. 242. 



120 



DISLOCATIONS OF THE LOWER JAW. 



upon the articular eminence. Still, as the masseter is relaxed in opening 
the mouth, the contraction of these fibres cannot be invoked as a cause 
of dislocation, although it was offered by Petit in explanation of the fixity 
of the dislocated jaw ; but the cause, when muscular, is rather to be 
found in the excessive action of the external pterygoid, aided by relaxa- 
tion of the external lateral ligament, which latter condition is produced 
by the wide opening of the mouth, as will be explained more fully in the 
following section. 

Pathology. — The opportunities directly to examine cases of dislocation 
of the jaw have been very few, and experiments upon the cadaver cannot 
entirely take their place, but it appears to be established that Malgaigne's 
opinion that the condyle did not advance more than one or two milli- 
metres beyond the point on the articular eminence which it normally 
reaches is not correct, but that the advance is considerably greater. In 



Fig. 17. 




Nelaton's specimen of dislocation of the lower jaw in which the coronoid process was caught below 
the malar bone. (Malgaigne.) 

an autopsy made by Demarquay in a case of recurrent dislocation the 
condyle was displaced four centimetres forward from the glenoid cavity 
and was in front of the transverse part of the zygoma ; the interarticular 
disk was behind it. It also appears that the rupture of the capsule, when 
it occurs, takes place in front between the meniscus and the condyle, but 
sometimes the meniscus accompanies the condyle without rupture of the 
capsule. This makes the persistence of the dislocation, and especially 
the fixation of the jaw, difficult to explain. The earliest theory, that of 
Petit above referred to, the contraction of the posterior fibres of the 
masseter, is generally rejected as inadequate. Another, also advanced by 



DISLOCATIONS OF THE LOWER JAW. 



121 



the earlier writers and recently brought forward again by Nelaton and 
accepted by Malgaigne, and supported by at least one specimen, which 
is figured in Malgaigne's Atlas, Plate 17, Fig. 1 (Fig. 17), is that the 
coronoid process becomes engaged under the malar bone. That this may 
be an occasional adjuvant cause must be admitted on the facts presented, 
but that it is not the sole cause, and probably not even a frequent one, is 
proved by experiments upon the cadaver which have shown the fixation 
to persist after removal of the coronoid process, and by the fact that in 
Nelaton's specimen the process is unusually long. 

The slightly upward inclination of the anterior surface of the eminentia 
articularis against which the displaced condyle rests is not of itself suffi- 
cient, and the most recent theory, suggested by Demarquay 1 and thor- 
oughly studied by Mathieu, 2 that the return of the condyle is opposed by 
the meniscus beyond which it has passed, seems to be open to the objec- 
tions that the meniscus is so freely movable backward that it would be 
readily pushed back into the glenoid cavity by the returning condyle, 
and that in some cases it accompanies the condyle in its excursion. An 
autopsy reported by Perier 3 of a case of recurrent dislocation showed 
absence of the anterior portion of the meniscus and lodgement of the 
remainder behind the condyle after reduction. It proves, therefore, not 
that the meniscus is the cause of the fixation, but that it may prevent 
complete reduction. 

The cause must be found, I think, in the ligaments, the external lateral 
and perhaps the posterior portion of the capsule, and this opinion is sup- 
ported by the tenseness of the lateral ligament observed by Weber 4 and 
Maisonneuve 5 upon the cadaver, and by the anatomical relations of the 
parts. The mechanism of its action I conceive to be as follows : The 

Fig. 18. 





Diagrammatic of the external lateral ligament of the lower jaw. A, when the mouth is open. 
J3, when the condyle is dislocated forward. 

external lateral ligament, forming the anterior part of the outer portion 
of the capsule, extends from the articular eminence downward and back- 
ward to the neck of the condyle, its attachment to the eminence being 
posterior to the point at which the under surface of the latter begins to 
incline upward. This ligament (Fig. 18) is too short to allow the jaw to 
take such a position when the condyle is dislocated forward that the long 



1 Demarquay : Bull, de la Soc. de Chirurgie, 1863, vol. iv. p. 119. 

2 Mathieu: Arch. gen. de Med., 1868, ii. p. 1*29. 

3 Perier : Bull, de la Soc. de Chir., 1878, p. 222. 

* Weber: Handbuch de Allg. and Spec. Chir., vol. iii. Abt. 1. p. 288. 
5 Maisonneuve : Comptes rendus, Acad, des Sciences, 1862, p. 654. 



122 



DISLOCATIONS OF THE LOWEE JAW. 



axis of the neck shall coincide with that of the ligament. When the 
mouth is widely opened the ligament is relaxed by the approximation of 
its points of attachment, and the condyle passes forward ; then, as the 
mouth is partly closed, the ligament becomes tense before the condyle 
has moved back .past it, and thus its further movement backward is pre- 
vented, and while it remains thus displaced any force that tends to close 
the mouth increases the obstacle to replacement by making the ligament 
more tense and pressing the bones more firmly together. Such a force 
is naturally and constantly exerted by the powerful muscles of mastica- 
tion, stimulated to contraction as they are by their forcible elongation 
and the pain and anxiety of the patient. The practical inference to be 
drawn from this explanation, if it is correct, is that reduction should be 
sought, not by crowding the body of the jaw downward and backward by 
pressure upon the molar teeth, but by first depressing the chin if possible, 
opening the mouth wider, so as to relax the ligament, and then pressing 
the condyle backward and closing the mouth as it passes the articular 
eminence on its way back. 

Fig. 19. 




Bilateral dislocation of the lower jaw. (R. W. Smith.) 

The symptoms of bilateral dislocation forward are that the mouth is 
held open, the lower jaw immovable and projected somewhat forward; 
exceptionally, only the projection is present, and the mouth can be 
closed. 1 Speech is indistinct, swallowing difficult, and chewing impossi- 
ble. The condyle can be felt in the temporal fossa in advance of its 



1 Some authors say that not only is the jaw protruded, but its angle is nearer the 
sterno-cleido-mastoid, a combination which cannot be explained, except by flexion of 
the head upon the neck. It seems more probable that it is an error of observation. 



DISLOCATIONS OF THE LOWER JAW. 



123 



usual position ; there is a prominence above the zygoma due to the raising 
of the posterior fibres of the temporal muscle, and a depression marking 
the empty glenoid cavity can be felt in front of the ear. The cheeks are 
flattened, and the saliva escapes from the mouth. The masseter and 
temporal muscles are usually tense, and the upper anterior portion of the 
former raised by the coronoid process. 

Fig. 20. 




Dislocation of the jaw of long standing. (R. W. Smith.) 

If the dislocation is unilateral the physical signs are found upon only one 
side, the chin is turned to the opposite side, and the functional disability 
is less. 

The prognosis is favorable both as regards the reduction of the dislo- 
cation and the degree of disability if it remains unreduced, but some- 
what unfavorable in that recurrence is quite probable. If it remains 
unreduced the parts appear slowly to adjust themselves to their new 
relations and finally to permit more or less satisfactory approximation of 
the jaws and restoration of the functions. 

Treatment. — The dislocation is one which, as a rule, can be easily 
reduced, one indeed in which, as has been already said, reduction has 
often occurred spontaneously. The methods employed have, perhaps in 
consequence of this fact, been numerous, and have varied greatly in the 
objects aimed at, if not in the actual mechanism by which they have 
accomplished the reduction. It can be shown, I think, that many of the 
methods and procedures have been successful not because they met the 
ideas of their originators concerning the obstacle to be overcome, but 
because they overcame or avoided another obstacle which had not been 
recognized. With few exceptions the aim of the different methods has 
been directly to depress the condyle and then to press it backward, and 



124 DISLOCATIONS OF THE LOWEE JAW. 

this aim has been accomplished by direct pressure downward upon the 
molars, or indirectly by raising the chin after having placed a wedge 
between the back teeth. Those who found the obstacle in the hooking of 
the coronoid process under the malar bone sought to disengage the pro- 
cess by opening the mouth more widely, and then pressed the jaw back- 
ward ; while others, again, pressed the bone directly backward by placing 
the thumb and forefinger of one hand against the coronoid processes and 
then elevated the chin by a slight blow upon it from beneath. It is note- 
worthy that some of the gentlest methods, some which approach most 
closely to that which I conceive to be the rational method, were employed 
by the earliest surgeons, even by Hippocrates, and were again and again 
resumed only to be as often neglected and forgotten. Hippocrates's 
method, as quoted by Malgaigne, was to lower the chin a little in order, 
according to Galen, to free the coronoid process from the malar bone, 
and then to press the jaw backward, the patient being meanwhile encour- 
aged to relax his muscles and yield himself as completely as possible to 
the effort made in his behalf. Although the intention and the supposed 
effect was to free the coronoid process, yet the wider opening of the 
mouth relaxed the lateral ligaments and facilitated the backward propul- 
sion. 

In 1862 Maisonneuve again revived the plan, after having observed in 
many experiments upon the cadaver that the external lateral, spheno- 
maxillary, and stylo-maxillary ligaments were tense and that after their 
division the dislocation could be reduced with great ease. His experi- 
ments were made at a time when the muscles were still looked upon as 
the great opponents of reduction, and it is not surprising that he should 
have failed to recognize the full significance of his observations and should 
have obscured the part taken by the ligaments by laying equal if not 
greater stress upon the action of the muscles. He ascribed the fixation 
to the pressure of the condyle against the zygoma, a pressure " main- 
tained by the combination of the passive resistance of the ligaments and 
the energetic contraction of the elevator muscles, " and proposed to reduce 
by direct backward propulsion after diminishing the pressure by opening 
the mouth more widely. His proposal, notwithstanding his high 
authority, does not appear to have been favorably received, possibly 
because the manoeuvre which would diminish the tension of the liga- 
ments would at the same time increase that of the muscles and thus leave 
the pressure as great as it was before, and his views, when mentioned by 
subsequent writers, are classed with those which attribute the obstacle to 
the contraction of the muscles. 

It is unquestionable that in this, as in most other dislocations, the 
obstacles to reduction are multiple, and that contraction of the muscles 
is one of them, and that it especially opposes reduction because it directly 
resists the attempt to place the bones in the most favorable position. It 
is also true that methods of reduction are habitually successful which are 
not based upon correct anatomical principles, but nevertheless those prin- 
ciples exist and are the same as in other dislocations ; the opposing liga- 
ments must be relaxed, and the bone should follow in returning to its 
socket the route by which it escaped from it. In the great majority of 
cases, as has been said, dislocation takes place while the mouth is widely 



DISLOCATIONS OF THE LOWER JAW 



125 



open and the ramus is inclined upward and forward. Theoretically, then, 
the same position should be given to it as a preliminary to reduction, and 
although the opposition of the muscles may create practical difficulties in 
the way of accomplishing this which will prevent its universal use and 
cause other methods to be preferred in the simple cases, yet in all difficult 
cases and whenever this opposition has been annulled by anaesthesia this 
method should be employed, the mouth should be widely opened and the 
jaw should be pressed backward, or backward and slightly downward. 
This pressure may be conveniently made by the thumbs placed inside or 
outside the mouth against the anterior edges of the ascending rami, the 
head of the patient being solidly supported behind. Possibly the expe- 
dient of reducing each side separately would prove as advantageous in 
this method as it has in others. 

In the method by forcible depression of the posterior portion of the 
jaw the thumbs may be used alone by placing them upon the lower molar 
teeth and pressing downward and backward. It is well to guard them 
against bruising by covering them with cloths or leather, and when the 
reduction is accomplished they should be rapidly withdrawn or slipped to 
the outer side of the teeth to escape being bitten, an accident that has 
happened to several surgeons and has indeed been the cause which led to 
the invention of other procedures. 

Instead of direct pressure with the thumbs, wedges of wood have been 
used, as have also hinged instruments, taking their bearings upon both 
sets of molars. Of the latter, Stromeyer's forceps (Fig. 21) are the 
simplest and best known. 

Fig. 21. 




Stromeyer's forceps. 

In cases of long standing in which adhesions have formed and must 
be ruptured before reduction can be made, these forcible measures are 
necessary, for the jaw cannot otherwise be moved through a range suffi- 
cient to accomplish the object. Reduction has been obtained as late as 
the ninety-eighth day after the occurrence of the dislocation. 

Mazzoni treated an irreducible bilateral dislocation of eight months' 
standing in a woman twenty-seven years old by excision of both condyles, 
with an excellent functional result. 

After reduction the mouth should be kept closed by a bandage and the 
patient fed on soft food for two or three weeks. It is not unlikely that 
the marked tendency to recurrence so commonly observed is the result of 
inopportune use of the jaw, perhaps also, in part, of the favorite method 
of reduction which tends to elongate or rupture the lateral ligaments. 

Genzmer 1 has proposed to treat the tendency to recurrence by injec- 

1 Genzmer : Centralblatt fiir chirurgie, 1883, p. 563. 



126 



DISLOCATIONS OF THE LOWER JAW, 



tions of pure tincture of iodine into the joint, a method which he has 
successfully employed in the similar condition at the shoulder. The 
joint is sought in front of the tragus of the ear at the lower border of 
the zygoma, and the injection should be repeated several times at inter- 
vals of three or four days. It does not appear from the abstract of the 
paper in which the method is set forth whether it has been employed at 
the jaw or not. 

Annandale 1 has recently treated two cases successfully by opening the 
joint and suturing the meniscus to the periosteum. "An incision, slightly 
curved, about three-quarters of an inch in length, is made over the pos- 
terior margin of the external lateral ligament of the joint, and is carried 
down to its capsule. Any small bleeding vessels having been secured, 
the capsule is divided, and the interarticular cartilage is seized, drawn 
into position, and secured to the periosteum and other tissues at the outer 
margin of the articulation by a catgut suture.'' 

Fig. 22. 




# f 




Congenital dislocation of the lower jaw. (R. W. Smith.) 

Pathological or consecutive dislocations are uncommon, and only in a 
few cases 2 has the condyle, eroded and deformed by antecedent inflamma- 



1 Annandale: Lancet, 1887, I. p. 411. 

2 Gurlt : Path. Anat. der Gelenkkrankheiten, p. 109, Cases 5, 11, 15. 



DISLOCATIONS OF THE LOWER JAW. 127 

tion, been found outside its cavity and sometimes united by bony union 
to the skull. 

Congenital Dislocations. — The only example of this condition of which 
I have found mention, if a foetal monster reported by Guerin be excepted, 
is one described by R. W. Smith 1 (Fig. 22). The patient was a con- 
genital idiot who died at the age of thirty-eight years. The dislocation 
existed upon the right side and was the result of defective development 
of the constituent parts of the joint. u When the mouth was closed the 
external lateral ligament of the lower jaw, instead of being directed 
backward, was seen descending obliquely forward, to be attached to a 
very imperfectly developed condyle, which was not in contact with that 
portion of the temporal bone which, in the natural state, corresponds to 
the glenoid cavity, being separated from it by an interval of at least a 
quarter of an inch. There was neither an interarticulate cartilage nor 
cartilage of incrustation, the osseous surfaces of the joint being invested 
by thick periosteum alone." 

" The right side of the inferior maxillary bone was considerably smaller 
than the left, the atrophy extending nearly to the symphysis and affecting 
the bone as to its length, breadth, and thickness, the ramus being half 
an inch less in its transverse diameter, and its parotideal margin half an 
inch shorter than upon the opposite side. . . . The parotideal 
margin, thin, concave at its upper part, and forming nearly a right angle 
with the body of the bone, terminated above in a small curved process 
directed nearly horizontally inward. . . . This process, which in 
form somewhat resembled the coracoid process of the scapula, was the 
only vestige of the existence of a condyle, and was destitute of cartilage." 

" The deformity of the temporal bone consisted in an arrest of develop- 
ment of the zygomatic process. The superior or longitudinal root 
existed, but the transverse root or articular eminence was absent, there 
being in its place merely a flat surface destitute of cartilage. At the 
point where the two roots meet in the normal state, or, in other words, at 
the tubercle of the zygoma, the temporal was joined to the malar bone, 
the suture which connected them being distant only half an inch from 
the circumference of the external auditory canal, while upon the opposite 
side the interval was one inch and a half." 

The right superior maxilla and right half of the sphenoid were also 
smaller than those of the left side. 

i R. W. Smith : Fractures and Dislocations, p. 273. 



CHAPTEE XII 



DISLOCATIONS OF THE VERTEBRAE AND OF THE OCCIPUT FROM THE ATLAS. 

The study of dislocations of the vertebras is closely associated with 
that of fractures of the same bones, because in many cases the differential 
diagnosis between a fracture and a dislocation cannot by made with cer- 
tainty, and because the associated lesions and consequences are the same. 
For some of the latter, therefore, the reader is referred to the chapter on 
Fractures of the Vertebras. 

Concerning the frequency of dislocations of the vertebrae widely dif- 
ferent opinions have been held ; some (Delpech) denying even the pos- 
sibility of dislocation without fracture, others thinking them extremely 
rare, and others, again, claiming that they are quite common. The 
most notable member of the last group is Porta, who, according to Blasius, 
observed no less than twenty-seven cases in thirty years. By far the 
most valuable contribution to the settlement of this question, and indeed 
to the whole subject, is the monograph of Blasius, 1 who collected 294 
reported cases, of which 185 were dislocations, 37 diastases, and in 72 it 
remained undetermined to which of these two classes the lesion belonged. 
Although an autopsical examination was made in 174, yet in 38 of these 
the account is so defective that the variety and seat of the injury cannot 
be determined ; and in only 172 of the 294 cases can these details be 
said to have been established. By far the most common seat is the cer- 
vical region, then the dorsal, and last the lumbar region, in which only a 
very few cases have been observed. 

This difference in the frequency of occurrence in the several regions 
has been habitually referred to alleged corresponding differences in their 
normal mobility ; but the explanation is somewhat lacking in precision. 
The mobility of the different parts of the spinal column, as described by 
Weber, 2 and most later anatomists, is as follows : Antero-posterior flexion 
and extension is slight, or almost absent, between the second and third 
cervical vertebrae, is most marked from there to the fifth or seventh, is 
less between the sixth and seventh, and still less between the seventh and 
the first dorsal. It is very slight between the upper seven dorsal, some- 
what greater in the lower ones, and very distinct between the last two 
dorsal and the first two lumbar, and between the fourth and fifth lumbar 
and the fifth lumbar and the sacrum. Lateral mobility is greatest in the 
first six cervical, less between the seventh cervical and the first dorsal, 
very slight in the first six or seven dorsal, and then usually increases 
downward through the lumbar region. Rotation is most marked in the 

1 Blasius: Die traumatische Wirbelverrenkungen, in Vierteljahrschrift fur prakt. 
Heilkiinde, 1869, vols. cii. ciii. 

2 Meckel's Archiv fur Anat. und Physiol., 1827, p. 240. 



DISLOCATIONS OF THE VERTEBRJ. 



129 



cervical, is slight in the upper dorsal, becomes again very marked from 
the eighth to the eleventh dorsal, is then less to the first lumbar, and is 
practically absent in the remaining lumbar vertebrae. It appears, there- 
fore, that while the greatly preponderating frequency of dislocations of 
the cervical vertebra? corresponds with greater normal mobility of that 
region, yet dislocations of the less movable dorsal are much more fre- 
quent than those of the more movable lumbar vertebras. 

Blasius gives the following table of the actual frequency at different 
ages: 

Table YIT. — Dislocations of the Vertebrae. 



Age. 


Cases. 


Age. 

! 


Cases. 


Certain. 


Doubtful. 


Certain. 


Doubtful. 


1 to 5 years . . . 

6 " 10 " ... 
11 " 15 " ... 
16 " 20 " ... 
21 " 30 " ... 
31 " 40 " ... 


1 
6 
9 
8 
25 
18 


3 

4 
2 

2 

10 

8 


41 to 50 years . . . 
51 " 60 " ... 

60 •* ... 

"Child" . ... 
"Adult" . ... 


14 
6 
1 

1 
9 


4 
1 
6 



Of 40 cases collected by Richet, 1 the age in only 11 was more than 
forty years, and in only 3 more than fifty years. This greater frequency 
in those of middle life must be referred to the greater exposure to the 
accidents that are apt to produce the lesion incident to their occupation, 
an explanation which is corroborated by the much greater frequency of 
the injury in males than in females : according to Blasius, 4 to 1 in the 
cervical region, and 12 to 1 in the dorsal. 

The difference of opinion above mentioned regarding the frequency of 
the occurrence of the injury in general, doubtless depends in part upon 
the definitions which the different authors have adopted, since some 
accept as dislocations only those cases which are not complicated by 
fracture, while others accept also those in which an associated fracture 
can be rightly deemed unessential to the production of the dislocation. 
The latter view is in harmony with the classification of other dislocations, 
and will be adopted here ; a dislocation of a vertebra being defined as an 
injury in which the adjoining articular processes on one or both sides 
have been partly or completely separated from each other, with or with- 
out avulsion of portions of the body of either vertebra or fracture of one 
or more processes. The term diastasis is applied to those dislocations 
in which, the intervertebral disks and other ligaments having been torn, 
the vertebrae are longitudinally separated from each other in front or 
behind, but have not also been so horizontally displaced that the articular 
surfaces on either side have been put out of line with each other. 

The terminology employed to indicate the seat and variety of the dis- 
placement has also varied with the different writers, some speaking of 
the upper, others of the lower, vertebra as the one that is dislocated, 



Richet: Anatomie Medico-Chirurg., p. 247. 



130 



DISLOCATIONS OF THE VERTEBRA 



while others have sought to avoid misunderstanding, by using such a 
phrase as " dislocation of the fifth upon the sixth." The latter form can 
be advantageously employed in the report of cases, or whenever any 
doubt might arise as to the meaning, but it will be convenient here to 
follow the more general practice, and speak of the upper vertebra as the 



Fig. 23. 




Cervical vertebra. (Gray.) 
1. Anterior tubercle of transverse process. 2. Foramen for vertebral artery. 3. Posterior tubercle of 
transverse process. 4. Transverse process. 5. Superior articular process. 6. Inferior articular process. 

one that is dislocated, and of the direction and character of its displace- 
ment, as those of the dislocation. 



Fig. 24. 







Dorsal vertebra. (Gray.) 

1. Superior articular process. 2. Facet for tubercle of rib. 3. Demi-facet for head of rib. 

4. Demi-facet for head of rib. 5. Inferior articular process. 



DISLOCATIONS OF THE VERTEBRA. 



131 



Fig. 25. 



Classification and Pathology. — The relations of the vertebrae to each 
other are so complex, and the combinations of different directions which 
the displacements may present are so variable and numerous, that a 
classification of the varieties based upon these directions is not only 
very complicated, but it also fails to offer comparative advantages suffi- 
cient to compensate for its complexity. The classification made by 
Hueter, according, to the character of the movement or the direction of 
the force which produces the dislocation, is simple, and at the same time 
indicates the main features of the displacement and suggests the proper 
method of reduction. It fails, however, to distinguish between the varie- 
ties ; and, therefore, while adopting it, it has appeared desirable also to 
use in connection with it other terms indicative of special features. 

The provisions for normal motion between adjoining vertebrae consist 
in the elasticity and compressibility of the intervertebral disks between 
the bodies, and in the articulations placed just 
behind those upon the arches. The normal range of 
motion, though varying in the different portions of 
the column, is at best slight, and can be referred in 
the main to two axes for each pair, one of which 
lies in the median plane and passes through the 
centre of the disk from behind forward, with an 
inclination downward of its anterior end which is 
slight in the lumbar and lower dorsal regions, more 
marked in the upper dorsal, and greatest in the 
cervical regions (Fig. 25). The other axis is a hori- 
zontal transverse one, passing through the posterior 
part of the disk. Motion about the first axis pro- 
duces a lateral bending of the column, and, in the 
cases in which the axis is inclined downward and 
forward, with this motion must be associated a rota- 
tion of the upper vertebra, by which the anterior 
surface of its body is turned to the side toward 
which the column is inclined ; and the greater the 
inclination of the axis, the more marked is this asso- 
ciated rotation. 1 The movement is arrested by the 
contact of the margins of the adjoining articular 
surfaces with their bases on the concave side, and if 
it persists beyond this point dislocation is produced, 
the opposite inferior articular surface of the upper 
vertebra being raised above the one with which it 
articulates by the lateral bending, and being carried 
forward by the rotation. To these dislocations 
Hueter gives the name dislocations by abduction or 
rotation. 

Motion about the other, transverse, axis produces a bending forward 
(or, to a less degree, backward) of the column, during which the ante- 




Direction of the median 
axis in the different sec- 
tions of the spinal column. 

(Henke ) 



1 This normal rotation toward the concave side should not be confounded with the 
pathological rotation toward the convex side observed in scoliosis ; the latter is, in 
part at least, produced by a progressive asymmetry of the vertebra itself, the short- 
ening of the pedicle upon the convex side. 



132 DISLOCATIONS OF THE VEETEHKJ], 

rior portion of the disk is compressed, the posterior portion stretched, 
and both inferior articular surfaces of the upper vertebra moved upward 
and forward along the superior articular surfaces of the underlying 
vertebra. The movement is checked, when its normal limit is reached, 
by the ligaments of the joints and arches, and, if these yield, a dislocation 
is produced, in which the inferior articular processes of the upper vertebra 
pass forward and in front of those with which they articulate — dislocation 
by flexion. 

Under the first head, dislocations by abduction, are to be included the 
complete or incomplete unilateral dislocations forward or backward, and 
the bilateral dislocations in opposite directions, described as distinct 
forms under these names by Blasius, all of which, with one exception 
(the unilateral dislocation backward), represent only different degrees of 
the same displacement. Instead of being entirely separated from each 
other, the articular surfaces may remain in contact at their edges (incom- 
plete dislocation). If the displacement is somewhat greater, the inferior 
process of the upper vertebra passes further forward, and sinks into the 
notch between the body and the superior articular process of the lower 
vertebra (complete unilateral dislocation) (Fig. 26), and at the same time 

Fig. 26. 




Complete unilateral dislocation by rotation or abduction ; cervical vertebra. (KSnig.) 

the inferior process on the opposite side may be carried backward by the 
movement of rotation (bilateral dislocation in opposite directions). 
Blasius quotes four cases in which the latter variety was observed and 
verified by post-mortem examination ; the dislocated vertebra w T ere the 
second, fourth, and fifth cervical, and the eleventh dorsal, and the dislo- 
cation was forward on the left side in the first three, and forward on the 
right side in the last one. The unilateral dislocation backward, of which 
Blasius refers to a few examples exclusive of those of the occiput upon 
the atlas, may, I think, be attributed to the same mechanism, the dis- 
placement being effected in consequence of the yielding of the ligaments 
of the joint on the side toward which the body is bent, instead of on the 
opposite side as in the other cases. In a case observed by Cloquet, and 
briefly mentioned by Blasius, the second lumbar vertebra was dislocated in 
this manner, the dislocation being complicated, but unessentially, by 
fracture of the body and arch of the vertebra ; all the processes were 
uninjured. The patient survived several years, and the condition of the 
parts was determined by autopsical examination. Under the second 
head, dislocations by flexion, are included bilateral dislocations forward 






DISLOCATIONS OF THE VEETEBEJ1. 133 

or backward. The force continuing to act after the normal limit of 
forward flexion of the column has been reached, the ligamenta subflava 
are ruptured, and the posterior portion of the intervertebral disk is torn 
or separated from the vertebra with or without avulsion of a portion of 
the bone, the articular processes of the upper vertebra lodge in front of 
those of the lower in the notches. Sometimes the processes do not pass 
entirely beyond each other, but remain in contact at their extremities ; 
and sometimes, the movement being accompanied by slight rotation of 
the vertebrae upon each other, one articular process is displaced further 
forward than the other. The lumen of the vertebral canal may be 
seriously encroached upon in this dislocation, and its contents injured by 
compression against the upper edge of the body of the lower vertebra. 

The mechanism of the double dislocation backward, of which a few 
cases have been accurately observed, has not been demonstrated, but the 
possibility of its production by extreme dorsal flexion of the column is 
such that it may, provisionally at least, be placed in this class. Its com- 
parative rarity is to be explained by the infrequency with which the trunk 
is exposed to this movement, and by the greater resistance to dislocation 
which arises from the relations of the bones. The motion is arrested by 
bony contact at the arches, and by the intervertebral disks, the efficiency 
of whose resistance is increased by their greater distance from the fulcrum 
about which the rupturing movement must turn. It is interesting to 
note that in a case reported by Stanley, 1 dislocation backward of the fifth 
cervical vertebra, the upper five vertebrae were firmly united together by 
bony fusion. The displacement was so great that the body of the fifth 
rested upon the laminae and spinous processes of the sixth. The addi- 
tional leverage created by this ankylosis may be invoked as an argument 
in favor of the theory of production by dorsal flexion. 

Transverse dislocation has been diagnosticated in several cases, but 
the only one in which sufficient anatomical proof has been obtained is one 
mentioned by Charles Bell. 2 A child was run over by a stage coach and 
died of croup thirteen months later. The last dorsal vertebra was found 
completely displaced to the left side of the first lumbar with slight chipping 
of the bone. The articulation between these vertebrae is of such a char- 
acter that this form of dislocation would seem impossible without fracture 
of the articular processes, and probably it may still properly be deemed so 
except in a child. The same anatomical conditions exist in the lumbar 
vertebrae, but in the dorsal and cervical regions the articular surfaces look 
backward and forward or are only slightly inclined to one side, conse- 
quently this form of dislocation must then be regarded as possible. 

In the greater part of the dorsal region it would necessarily be asso- 
ciated with dislocation of the vertebral end of the corresponding rib. 

Bell's case and another involving the same vertebra reported by Mohr- 
enheim are quoted by Blasius but rejected on the ground that the primary 
dislocation was probably bilateral backward or forward, and the trans- 
verse displacement secondary. There is nothing in the original report of 
Bell's case to warrant this assumption, which must therefore rest on 

1 Stanley: Edinburgh Med. and Surg;. Journ., October, 1841, p. 404. 

2 Bell : Injuries to the Spine and Thigh Bone, 1824, p. 25. 



134 DISLOCATIONS OF THE VERTEBRJ. 

theoretical considerations alone. In all the clinical cases quoted by Blasius, 
with one exception, the cervical vertebrae were concerned, and he says 
that the correctness of the diagnosis is very doubtful in all. 

The main groups and varieties, then, are as follows : 
Dislocations by flexion, ventral or dorsal. 
Bilateral forward. 
Bilateral backward. 
Dislocations by abduction or rotation. 
Unilateral forward 1 complete or 
Unilateral backward j incomplete. 
Bilateral in opposite directions. 
Transverse (?). 

The associated lesions comprise rupture of the various ligaments, 
muscles, bloodvessels,. and nerves, fracture of the bones, and injuries of 
the spinal cord and its membranes, and those later changes which may be 
induced by the primary ones. 

The intervertebral disk is always ruptured or torn away from one or the 
other vertebra, and this rupture or separation is almost invariably com- 
plete, the exceptions having been found in a few of the slighter forms or 
in diastasis. The line of separation may run entirely within the sub- 
stance of the disk or between it and the body of the vertebra, but usually 
it combines the two forms and is accompanied by the avulsion of larger 
or smaller fragments of the bone. In one or two cases the disk appears 
to have been crushed. 

The capsular ligament, on one or both sides according to the char- 
acter of the displacement, is always torn. The anterior and posterior 
ligaments are either torn, wholly or in part, or stripped from their attach- 
ments to the bodies of the vertebrae, sometimes bringing with them in 
the latter case portions of the bone. The ligaments between the lamince 
and the spinous processes are either torn or put upon the stretch, and 
those between the transverse processes were torn in the only reported 
case found by Blasius in which their condition was mentioned. Instead 
of rupture of the ligaments fracture of the processes to which they are 
attached may occur, and various other fractures of the adjoining pro- 
cesses or of more distant parts are frequently observed. 

The surrounding and the attached muscles may be torn by the dis- 
placement or by the direct action upon them of the dislocating violence. 

Bloodvessels. — The veins coming from the bodies of the vertebrae and 
those of the meninges of the cord are so large and their relations with 
the bones and ligaments are so close that hemorrhage is always free and 
sometimes very profuse. In Robert's case 1 of backward dislocation of 
the fifth dorsal vertebra the blood escaped into the mediastinum and 
through the torn pleura into the pleural cavities ; in it also, as in many 
others, the adjoining muscles were extensively infiltrated with blood. 

In dislocations of the cervical vertebrae the vertebral arteries so com- 
monly escape injury that the possibility of their rupture has been denied, 
but in a case received into St. Thomas's Hospital 2 the vertebral artery 

1 Robert: Bull, de la Soc. de Chirurgie, September 21, 1853. 

2 Med. Chirurg. Rev., 1831, vol. 14 (18 of analyt. series), p. 227. 



DISLOCATIONS OF THE VERTEBEJ!. 135 

was found to have been torn and a large amount of blood to have escaped 
into the vertebral canal and among the muscles. Blasius admits this 
case into his list although all the processes of the fourth vertebra were 
broken. 

The nerve trunks at their point of emergence through the intervertebral 
foramina may be compressed or torn on one or both sides between the 
articular process of one vertebra and the body or pedicle of the other ; 
and in the lumbar or lower dorsal regions the nerves constituting the 
cauda equina have repeatedly been found torn across or compressed 
between the body and laminae of the adjoining vertebrae. 

The spinal cord and its membranes may entirely escape injury, and, 
if injured, the lesion may present any grade between simple compression 
and complete rupture. The injury may be caused by pressure of the 
bone against the cord or by the direct elongation of the latter. All the 
lining membranes may be torn, entirely across or only in part, or one of 
them alone may be ruptured. Their rupture is necessarily accompanied by 
the extravasation of blood, usually profuse, between the dura and the 
bone and amid the meninges. Occasionally an extravasation of blood has 
been found within the cord itself; thus, in a case reported by Martini, 1 
one of diastasis between the fourth and fifth cervical vertebrae, in which 
there was complete rupture of all the ligaments and separation to such 
an extent that the finger could be passed between the bones, the meninges 
were not torn, and the only lesion found in the cord was a clot three 
centimetres long in its centre and involving also the cortical substance. 
A similar case has recently been reported by Quenu. 2 It is worthy of 
note that in three reported cases 3 in which extensive paralysis was 
present the autopsy failed to show any lesion of the cord, and that in 
others there has appeared to be no* fixed relation between the extent of 
the paralyses and the anatomical lesions found in the cord. In other 
cases the cord has been found torn while the ligaments have been 
only slightly injured ; in one 4 of slight diastasis between the sixth and 
seventh cervical vertebrae produced by hanging, the pedunculi cerebri 
were found completely torn across. 

The analysis made by Blasius to determine the relative frequency and 
severity of injury to the cord in the different forms and at the different 
seats of dislocation shows that the danger is greatest in dislocation of the 
lower cervical vertebrae, the fifth and especially the sixth, although even 
there the cord may entirely escape injury. In the variety which he terms 
"unilateral forward" (dislocation by abduction or rotation) the danger is 
less than in the "bilateral forward" or "backward" (disocation by 
flexion) ; in 7 autopsies the cord was found injured in 6, and of 45 cases 
observed clinically, all of the neck, in 9 there was evidence of injury or 
compression of the cord, which disappeared in 5 and was followed in 4 
by inflammatory and softening processes in the cord. The variety which 

1 Martini: Schmidt's Jahrbiicher, 1861, vol. 110, p. 195. 

2 Quenu: Le Proves Medical, Feb. 27, 1887. 

3 Colborne : Provinc. Med. and Surg. Journ., vol. 2, p. 50 ; Hafner : Zeitschrift fur 
Wundarzte und G-eburtshelfer, 1856, vol. 9, p. 249 ; and Porta : Delia lussazioni della 
vertebre, 1864, quoted by Blasius. 

4 G-uerin : Gazette Mgdieale, 1853, p. 275. 



136 DISLOCATIONS OF THE VERTEBRJ. 

he terms "bilateral in opposite directions'' appears particularly free from 
this danger ; in the few cases he collected paralysis was exceptional and 
temporary. Of 8 cases of bilateral dislocation backward examined post- 
mortem, the cord was uninjured in 2, and more or less severely injured 
in 6 ; of 6 clinical cases, in 3 there was no paralysis, and in 3 the paral- 
ysis was temporary. Of 52 cases of bilateral dislocation forward, the 
cord was uninjured in 17, and was injured seriously and irreparably in 
11 ; in the remaining 24, either recovery followed or a distinction cannot 
be made between the effects of the mechanical violence inflicted upon the 
cord by the dislocation and those of the later inflammatory and nutritive 
changes. It must be remembered that in most of the clinical cases our 
knowledge of the exact character of the lesion of the skeleton is defective. 

Blasius (loc. cit., p. 130) summarizes the analysis as follows: in no 
form of dislocation is injury of the spinal cord a necessary consequence ; 
such injury is less to be expected in unilateral dislocation, and in uni- 
lateral dislocation forward of the cervical vertebrae it is always, or almost 
always, only a simple compression without crushing ; in bilateral disloca- 
tion backward or forward, either of the dorsal or cervical vertebrae, the 
cord is exposed to more serious lesions and seldom escapes entirely unin- 
jured, and when the displacement is forward the cord is mechanically 
affected in most cases, but the cases of severe injury are fewer than those 
in which all injury is escaped ; finally, the danger is least in bilateral 
dislocation in opposite directions. 

Secondary changes. — When the patients survive for a sufficient length 
of time the signs of a more or less acute inflammatory reaction appear. 
There is reason to believe that this reaction in the meninges and cord is 
not so frequent or severe as that which follows injury to the skull, but 
yet in a number of cases pus has been found in the meninges and even 
in the centre of the cord itself, as in a case mentioned in a paper by 
Coliny, 1 one of diastasis between the seventh cervical and first dorsal 
vertebrae with rupture of the ligaments of the articular processes, in 
which the cord at the level of the diastasis was found almost diffluent 
and containing in its centre a small focus of greenish-brown pus, which 
extended up to the level of the fourth cervical vertebra. The cord may 
be slightly softened and changed in color, or it may be reduced to pulp, 
and this change may involve only the portion corresponding to the dislo- 
cated vertebra or it may extend to a greater or less distance above and 
below, as in a case reported by Bryant 2 of dislocation of the eleventh 
dorsal vertebra in which it involved the entire length of the cord below 
the fourth dorsal. It is probable also that other changes observed after 
fracture of the vertebrae, such as extensive suppuration within the pia 
and the substitution of fibrous tissue for the nervous elements of the cord, 
may take place, for the conditions are practically the same. 

The intervertebral disk seems habitually to disappear by softening and 
absorption ; and the ligaments undergo changes similar to those observed 
in other ligaments — that is, their torn portions reunite by cicatricial 
tissue or they contract new attachments in the evolution of the process of 

1 Coliny : Archives Gen. de Med., 1836, 2d ser., vol. 10, p. 200. 

2 Bryant: Guy's Hosp. Kep., 1859, vol. 5, p. 80, case 45. 



DISLOCATIONS OF THE VERTEBRA. 137 

repair, and they may even become ossified. The tendency of the repara- 
tive process to end in suppuration, which has been observed to be excep- 
tionally marked after fracture of the vertebrae, has been manifested also 
after dislocation, although possibly only in cases complicated by fracture. 
In some of the reported cases it seems probable that the suppuration was 
primary -(caries of the body of a vertebra), and that the dislocation was 
the consequence of the changes produced by it in the bones and the 
ligaments. 

Etiology. — The causes have been habitually described as direct and 
indirect violence and muscular action, and to these Blasius adds u counter- 
stroke," as in a fall upon the buttocks with the trunk strongly flexed. 
The distinction between direct and indirect violence is made by classifying 
under the latter those cases in which the force has acted upon the column 
at some distance from the point of dislocation to bend it in one or another 
direction, and under the former those in which the force has acted directly 
upon the dislocated vertebra. But the mechanism — in most, if not in all 
cases — is certainly the same ; the column is forcibly bent, and the dislo- 
cation is produced by this forcible bending, just as a rod may be bent or 
broken by grasping and approximating its two ends with or without the 
aid of direct pressure against its centre. It seems highly probable also 
that in the cases attributed to " counter-stroke " the mechanism is the 
same ; the motion of the lower part of the column is arrested by impact 
against the ground, while the upper portion continues its descent, and 
thus the flexion is increased to the necessary degree, exactly as if the 
column had been bent by a force applied to its upper portion. In the 
cases of dislocation by muscular action the cervical vertebrae alone have 
been involved, and the movement has been that of exaggerated rotation. 

Symptoms and Diagnosis. — Most of the symptoms of dislocation are 
the same as those of fracture of the vertebrae. There is usually the same 
history of violence acting upon the spinal column, either directly or indi- 
rectly, to bend it beyond the limit of its normal range of motion, localized 
pain increased by movement or manipulation, inability to stand, partial 
or complete paralysis below the point of injury, diminution or exaggera- 
tion of the normal mobility of the affected part with or without reflex 
muscular rigidity of the upper segment of the column, and deformity 
recognizable by sight or touch. The symptoms which are thought to be 
of most service in establishing; the differential diagnosis between these two 
injuries are crepitation and abnormal mobility at the point of injury in 
fracture, and their absence in dislocation. Unfortunately, crepitation is 
not always obtainable in fracture by such manipulations as are permis- 
sible, and it may be present in dislocation accompanied by fracture — that 
is, in a condition in which the dislocation is the important injury, and 
the fracture a comparatively unimportant addition. Rigidity of the 
column at the injured point is common but not constant in dislocation, 
and it may be caused in fracture, or even in contusion or sprain, by 
muscular contraction. But while a positive differential diagnosis may 
not often be possible, a probable diagnosis may frequently be made, at 
least when the injury is in the cervical region, by attention to the attitude 
and rigidity of the neck, by recognition of the change in the relations of 
the transverse processes, or of the bodies of the vertebrae so far as they 



138 DISLOCATIONS OF THE VERTEBRA. 

are accessible to examination in the pharynx, or of the lower spinous 
processes, and by the impossibility of correcting the displacement by 
lateral pressure. 

On the other hand, muscular contraction and pain due simply to 
bruising of muscles or nerves or to inflammation of the vertebral joints 
may produce an attitude and rigidity closely resembling those of dislo- 
cation. 

The deformity consists in displacement of the spinous or transverse 
processes forward or backward or to one side, and is to be recognized by 
palpation. The displacement of the transverse processes, unless very 
great, can be recognized by touch only in the neck, that of the spinous 
processes everywhere except in the upper cervical region unless the 
patient is very fat. The body of the displaced vertebra is accessible to 
examination only in the pharynx and occasionally, as in a case reported 
by Dupuytren, by deep pressure through the anterior abdominal wall. 

Pain, although sometimes absent, is commonly present, and is provoked 
or increased by movements of the body or by direct pressure upon the 
injured region. It has its origin in the bruising or laceration of the 
adjoining soft parts and in pressure upon the nerves within the canal or 
at their point of exit through the intervertebral foramina. In some cases 
it is referred only to the point of injury, in others it is radiated along 
the course and over the region of distribution of the affected nerves. 

Paralysis, entirely absent in some cases, may be partial or complete 
within the affected region ; usually the two sides of the body are similarly 
affected (paraplegia), and limitation to a lateral half of the body (hemi- 
plegia) is unknown except where the paralysis has been only partial. 
Motor paralysis is, as a rule, more marked and extensive than sensory 
paralysis, and in a few cases the autopsy has shown anatomical differences 
in the extent of the injury to the different portions of the spinal cord 
corresponding to the differences in the extent of the motor and sensory 
paralyses observed during life. As a rule, paralysis of either kind is 
less marked in dislocation than in fracture. 

Paralysis is observed in the muscles of the column adjoining the point 
of injury (and this fact has been offered in explanation of the exaggerated 
mobility sometimes observed), in some or all of the parts of the body 
below the point of injury, and occasionally in those lying above it. This 
last mentioned extension is to be explained by mechanical injury to the 
cord at a higher point than the dislocation, as by over-stretching in dias- 
tasis, or by extravasation of blood, or by the extension of inflammatory 
processes set up by the injury. 

Instead of paralysis, or in association with it, may be observed muscular 
contractions, neuralgic pains, and hyperesthesia, presumably dependent 
upon inflammatory changes in the cord and meninges. In a few cases 
there have been general convulsions, promptly followed by death, and in 
one, 1 diastasis between the seventh cervical and first dorsal vertebrae, con- 
vulsions appeared at the end of the first week and were followed in rapid 
succession by trismus, renewed convulsions, mania, and finally, after 

1 Charles Bell : Inj. to the Spine and Thigh Bone, 1824, p. 9. 



DISLOCATIONS OF THE VERTEBRAE. 139 

disappearance of the former symptoms, by motor paralysis of the ex- 
tremities. 

The implications of the muscles of the trunk in the paralysis may have 
the most serious consequences, since it deprives the patient of control over 
the escape of urine and feces and of their voluntary evacuation, and also 
of the power of bringing into action the accessory muscles of expiration. 
If the injury is situated at a high point the action of all the muscles of 
inspiration except the diaphragm may be abolished, and if it is situated 
at or above the third cervical the latter muscle also may be paralyzed and 
the patient immediately dies asphyxiated. 

In addition to these symptoms of injury of the cerebro-spinal nerves 
and centres are others of widely different character and involving many 
different tissues and organs, which, as Hutchinson 1 has pointed out in a 
valuable and very interesting paper, may be referred to changes in the 
sympathetic, especially the vaso-motor system. Thus, sudden rises of 
temperature, general or local and of longer or shorter duration, may be 
observed, sometimes associated with pallor of the surface or with marked 
pulsation in the arteries. If the injury is in the cervical region the 
heart-beat becomes slow but does not also show the intermissions that 
commonly accompany the slow pulse of injury to the brain. 

Immobility of one or both pupils, with a slight degree of contraction, 
has been noted ; in other cases immobility with dilatation. 

Priapism frequently accompanies injury of the lower cervical and 
upper and middle dorsal regions when it is sufficient to cause paraplegia. 
Blasius found it most frequent in dislocations of the lower four cervical 
vertebrae, once in dislocation of the occiput from the atlas, only once in 
dislocations of the dorsal vertebrae (twelfth), and in none of the lumbar 
dislocations. Hutchinson says it is constant and well marked in disloca- 
tions of the upper and middle dorsal regions, but, as Blasius points out, 
this statement is too broad and is not borne out by the statistics. Its 
frequency, compared with all cases in males, was found by Blasius to be 
1 to 5 at the fourth cervical, 1 to 3.6 at the fifth, 1 to 2.7 at the sixth, 
and 1 to 2.5 at the seventh. He adds that it was present in fourteen out 
of twenty-five cases of fracture of the sixth cervical vertebra. The con- 
dition of the member appears, however, not to be that of normal physio- 
logical erection, but rather of simple engorgement, the member remaining 
comparatively flaccid although swollen. In a few cases the priapism has 
been provoked only by the additional application of a local irritant, as 
the passage of a catheter. 

The rapid formation of bedsores has also been attributed to vaso- 
motor or trophic changes, but while it is possible that such changes may 
act as a predisposing cause, yet the immediate, determining cause appears 
to be rather the prolonged, unrelieved pressure to which the parts are 
subjected in consequence of the paralysis. (See Fractures, p. 273.) 

The occurrence of cystitis and ammoniacal decomposition of the urine 
within the bladder has also been explained in the same manner, but it 
seems rather to be the consequence of over-distention of the bladder and 
of the use of the catheter. The later consequences of this cystitis are 

1 Hutchinson : London Hospital Eeport, 1866, vol. 3, p. 357. 



140 DISLOCATIONS OF THE VEKTEBR^, 

extremely serious and may hasten, or be the immediate cause of death. 
(See Fractures, p. 272.) 

Injury to or change in the vaso-motor nerves has been thought to be 
the cause also of changes sometimes observed in the lungs. In two cases 
elsewhere mentioned 1 I have known fracture of the cervical vertebrae to 
be followed by expectoration of blood coming from the lungs, and Blasius 
(following Moritz) describes a pulmonary congestion appearing promptly, 
marked at first by increased secretion, and rapidly causing death by 
oedema of the lungs, usually on the second or third day. 

Prognosis. — The injury is commonly deemed, and with good reason, 
one that places the life of the patient in great danger. Of the cases 
collected by Blasius the termination is noted in 278, and of these the 
injury caused death in 176 and was more or less completely recovered 
from in 102. These statistics, however, cannot properly be taken to 
indicate the actual percentage of mortality in such cases, because they 
are made up not from integral records but from published cases, and, as 
is well known, cases that survive are more frequently published than 
those that terminate fatally. Furthermore, as Blasius points out, the 
diagnosis is by no means certain in all of the recoveries, and in some of 
the fatal cases death may have been due to associated injuries. From 
these 278 cases Blasius took 159 in which the diagnosis was certain ; of 
these 36 recovered and 123 died, a proportion of 22.6 per cent, of 
recoveries, or 1 in 4.4, which corresponds quite closely with that established 
by Gurlt, 19.6 percent., for fractures of the vertebrae (see Fractures, p. 
254). It is well worthy of note, also, that of these 36 recoveries the 
dislocation was completely reduced in 27 and partly reduced in 2, and 
that all these 29 and 5 of the remaining 7 were dislocations of the cervical 
vertebrae. 

In the fatal cases death usually followed promptly upon the receipt of 
the injury. Of 113 authentic cases 21 died within the first twenty- 
four hours, 31 on the second and third days, 17 between the fourth and 
seventh days, 14 in the second week, 5 in the third, 6 in the fourth, 3 in 
the fifth, 2 in the sixth week, and the remainder at periods varying from two 
and a half to five months. Death, especially in the cases in which it occurs 
promptly, is usually the consequence of the injury to the cord or of the 
inflammatory processes set up in it by the injury ; but when this injury 
is situated in the lower portion of the cord life may be indefinitely pro- 
longed, as in the case quoted above from Charles Bell, in which by com- 
plete lateral dislocation of the twelfth dorsal vertebra the cord was com- 
pletely divided, and the patient, a child, died of croup thirteen months 
later. Simple compression of the cord involves less danger to life than 
its complete or partial division or crushing, and relief of the compression 
may be followed by restoration of function. If the compression takes 
place gradually, even to a very marked degree and at the upper end of 
the cord, as in several reported cases of cervical spinal caries, prolonga- 
tion of life is still possible, and even marked and permanent compression 
at the level of the atlas and axis has, in two reported cases, not proved 

1 Fractures, p, 262. 



DISLOCATIONS OF THE VERTEBRA. 141 

immediately fatal. In one 1 of these, dislocation of the atlas forward 
from both the occiput and the axis with fracture of the odontoid process, 
the canal was reduced to a triangular slit two millimetres wide on one 
side and five on the other ; the patient survived five months, being com- 
pletely paralyzed during most of the time. In the other case, 2 incom- 
plete dislocation of the occiput from the atlas due to caries, the patient 
survived three months and died of tubercle of the brain. 

If the dislocatioD remains unreduced the irregularities in the form and 
function of the column of course persist, and the irritation of the trau- 
matism may lead to such ossification of the ligaments and bony anky- 
losis of adjoining vertebrae as will still further diminish the mobility of 
the column and increase the chance of the occurrence of fracture, as in 
a case mentioned by Ollivier d' Angers. 3 

If the dislocation is reduced the symptoms usually disappear promptly, 
but the paralysis may persist in whole or in part, and the case may even 
terminate fatally in consequence of the injury done to the cord or its 
envelopes. 

Treatment. — This must be directed to the reduction of the dislocation, 
the prevention of its recurrence, and if reduction is impossible to the 
relief of the consequences of the displacement. The propriety of 
attempting reduction has been earnestly questioned, and many judicious 
surgeons have recommended that the attempt should be abstained from 
because of the possibility that it may add to the injury of the cord. 
Some (Nelaton) have suggested that the attempt should not be made 
unless the injury or its consequences have already placed the patient's 
life in imminent danger ; while others (Porta) have sought to restrict the 
attempt to those cases in which the cord has not been injured and the 
existing dislocation can be borne without serious trouble or disability. The 
reason for the last advice probably lay in the belief that if the cord were 
already so injured by the traumatism as to give rise to noteworthy symp- 
toms no good could be expected from reduction, a belief that is not in 
harmony with observed facts. The postponement of reduction until after 
the appearance of later symptoms due to the persistence of the irritating 
conditions is as unwise, as fatal, as similar temporization in the treatment 
of fractures of the skull. If anything is to be done it should be done 
promptly, and yet it must be added that reduction has been successfully 
made in several cases as late as the eighth or ninth day after the accident, 
and in one after the lapse of two months, and was followed by the prompt 
or gradual disappearance of the paralysis. 

The attempt to discriminate, with reference to the question of attempt- 
ing reduction, between cases in which the paralysis is due to simple 
compression of the cord and those in which it is due to its laceration or 
the effusion of blood within the canal is impracticable because of the 
impossibility of making a positive differential diagnosis between those 
conditions. 

The possibility that the attempt may cause the instant death of the 

1 Costes : Schmidt's Jahrbucb, vol. 79, p. 208. 

2 Darriste : Bull, de la Soc. Anatomique, 1838, vol. 13, p. 144. 

s Traite des Maladies de la Moelle epiniere, 3d ed. vol. 1, p. 276. 



142 DISLOCATIONS OF THE VERTEBRJ. 

patient, especially when the dislocation is in the upper part of the cervical 
spine, is a weighty factor in the problem but should not, in my judgment, 
deter the surgeon if the patient or his friends accept the risk. It should 
only stimulate him to make the most accurate possible diagnosis as 
regards the seat, direction, and mode of production of the dislocation, 
and most cautiously to select and execute the necessary manoeuvres. The 
urgency of the symptoms may leave him but scant time for observation 
and reflection, and the history of the case may throw no light upon the 
mode of production, so that the general rule to return the dislocated part 
along the path by which it escaped from its position cannot be knowingly 
and deliberately followed. Under such circumstances the surgeon must 
trust to traction aided by such flexion and rotation of the column as his 
best scrutiny of the displacement and knowledge of the relations of the 
articular processes may suggest. Anaesthesia should be employed unless 
contraindicated by the condition of the heart or respiration. 

The return of the bone to its place is usually indicated by a distinct 
sound, and the rigidity which is usually present gives place to normal 
mobility. 

If the dislocation is comparatively slight, moderate lateral pressure 
may effect reduction, as in a remarkable case reported to Blasius 1 by 
Richter. A lad, eleven or twelve years old, consulted Richter because 
of deformity and stiffness of the neck caused by a fall. He found the 
spinous process of the third cervical vertebra slightly displaced to one 
side, and that pressure upon it caused pain. No paralysis. An attempt 
to reduce the dislocation by traction on the head failed, and the child was 
sent home to await another attempt. On the way, the child, who had heard 
and comprehended the diagnosis, stopped by a wall, leaned his head and 
shoulder against it, and pressed forcibly with his thumb against the 
opposite, convex side of his neck, and instantly reduced the dislocation. 
The story was confirmed by the child's companions, and the surgeon 
found at his visit the neck straight, normally movable, and free from 
pain. 

In another case quoted by Blasius a dislocation of the third cervical 
vertebra had remained unreduced in spite of several attempts ; on the 
ninth day the patient fell out of bed, and reduction took place with an 
audible snap. 

After reduction has been made no other retentive measures than rest 
in bed are ordinarily required, but if there is reason to fear recurrence the 
parts may be immobilized by gypsum bandages or padded wire splints 
that embrace the entire trunk if the injury is situated below the 
shoulders, and the head and chest if it is in the cervical region. 

If reduction cannot be made immobilization is still necessary to favor 
the formation of firm adhesions and the solidification of the bones in 
their new relations ; and in addition measures may be needed to combat 
the inflammatory processes set up by the traumatism and to meet the 
indications of other symptoms. Of the latter the most urgent is the 
acute hyperemia of the lungs that has occasionally been observed, and 
this is most promptly and satisfactorily met by free venesection. The 

1 Blasius : Loc. cit., vol. 104, p. 114. 



DISLOCATIONS OF THE OCCIPUT. 143 

necessity of attention to the urinary bladder must not be overlooked, 
and although Hutchinson, in the paper above quoted, expresses the 
opinion that the disadvantages arising from the use of the catheter are 
greater than those following retention and relief by overflow, the con- 
trary opinion is very generally held. Possibly it would be well to remove 
the urine by aspiration above the pubes twice a day for the first two or 
three days rather than by catheterization, in the hope of the early restor- 
ation of control. M. D. Harrison 1 speaks highly of the value of per- 
manent antiseptic drainage of the bladder through a perineal incision in 
the treatment of " fracture-dislocations of the spine." Under its use he 
has seen not only the cystitis disappear, but also the bedsores heal and 
the paralysis diminish. 

Dislocations of the Occiput and Cervical Vertebrae. 

Dislocations are far more frequent in this region than in others, a fact 
that is to be explained by its greater exposure to dislocating violence, by 
the anatomical relations which permit greater freedom of motion, and by 
the relative weakness of the connecting ligaments. The fifth cervical 
vetebra is the one most frequently dislocated. The anatomical dhTerences 
between the articulations of the atlas with the occiput and axis and those 
of the other vertebrae are such that a separate description of the injury 
at the upper end of this region is necessary. 

Dislocations of the Occiput (from the Atlas). 

The articulations between the occiput and the condyles ,of the occipital 
bone are formed on each side by a long, oval articular surface on the 
atlas, which is concave both from before backward and from side to side ; 
the long axis of which runs from in front outward and backward and 
the outer margin of each is higher than the inner margin, so that each 
articular surface looks upward, inward, and backward, and together they 
constitute a cup-shaped socket into which the rounded condyles of the 
occipital bone fit, and upon which they have a motion only of flexion and 
extension. In addition to the ligaments uniting the two bones there are 
other and strong ones within the canal which directly unite the posterior 
surface and apex of the odontoid process with the occipital bone and 
thus aid in opposing the separation of the atlas from the latter. 

The dislocation was formerly deemed quite a common one, and to this 
opinion succeeded another more in harmony with the anatomical condi- 
tions of the joint but still erroneous, namely, that it had never occurred. 
There are, however, three observatiqns which positively demonstrate the 
occurrence of the injury, those of Costes, 2 Bouisson, 3 and Milner. 4 

1 Harrison: Liverpool Med. Chir. Journ., July, 1887. 

2 Costes: Schmidt's Jahrbuch, vol. 79, p. 208, and Malgaigne : Des Luxations, 
p. 329. Both these accounts are abstracts of the original report in the Journal de 
Bordeaux, August, 1852, and they differ materially from each other in some points. 
In the account here given I have in the main followed the former, since Malgaigne's 
appears to have been taken from an abstract, not from the original paper. 

3 Bouisson: Schmidt's Jahrbuch, vol. 82, p. 216, from Kevue Med. Chirurg. de 
Paris, vol. 2, p. 355. 

i Milner : St. Bartholomew Hosp. Bep., vol. 10, p. 314. 



144 DISLOCATIONS OF THE OCCIPUT. 

In the former a lad fifteen years old was thrown down and beaten upon 
the back of the neck, by which the atlas was displaced forward from its 
articulations with both the occipital bone and the axis, and the odontoid 
process of the latter was broken off. The patient's head remained 
inclined forward, and movements of the neck were difficult. A few days 
later hyperesthesia and paralysis of motion appeared, and persisted, 
without treatment, for four months ; then the right arm and leg became 
painful and he was taken to the hospital. The pulse was feeble and 
slightly quickened ; at the posterior part of the neck was a firm swelling 
projecting a little on the right side which subsequently proved to be the 
posterior part of the axis, and the chin was turned to the left and so 
depressed as almost to touch the chest. He died thirty-six days after 
admission to the hospital. 

At the autopsy the skull was found dislocated backward from the 
atlas, the articular surfaces being completely separated on the right side, 
while on the left the anterior and inner part of the articular surface of 
the condyle was still in contact with the posterior part of that of the 
atlas. At the same time the atlas was tilted forward, rotated to the left 
in front and to the right behind, and displaced forward upon the axis ; 
the odontoid process was broken off at the base and reunited by fibrous 
tissue in an almost horizontal position with the body of the axis. The 
posterior arch of the atlas was so closely approximated to the body of 
the axis that the interval between them was reduced to a triangular slit 
five mm. wide on the left side and two mm. on the right. 

In the second case, Bouisson's, a lad sixteen years old was thrown 
down upon his face and instantly killed by the fall of a heavily laden 
cart, the edge of which pressed upon the upper part of the back of his 
neck. The right condyle of the occipital bone was displaced backward 
from the corresponding articular surface of the atlas for a distance of two 
centimetres, with rupture of the capsular ligaments ; on the left side the 
ligaments were torn but the articular surfaces were not displaced from 
each other. The posterior occipito-atlantoid and the right alar and 
occipito-odontoid ligaments were torn, and the muscles of the neck were 
extensively lacerated and contused. A large extravasation of blood 
extended upward from the spinal canal between the dura mater and cere- 
bellum, and the medulla was greatly compressed but not torn. 

In Milner's case a man thirty-eight years old fell from a height of 
seventy feet and was taken up dead. The head was freely movable, 
and capable of being so displaced to either side that the top of the 
spinal column would form a projecting tumor in the neck. There was 
found " complete dislocation of the occipital bone from the atlas and 
axis, all the ligaments on both sides which connected them with the 
occiput were completely torn across." The posterior arch of the atlas 
was broken off transversely where it joins the lateral masses. The 
odontoid process was cracked longitudinally, but there was no dis- 
placement between the atlas and the axis. The medulla oblongata and 
the vertebral arteries were divided. 

In connection with these may be mentioned several other cases of 
which the histories are so defective that the exact nature of the lesion 
remains in doubt. Some of them are given in the article by Bouisson 



DISLOCATION OF THE ATLAS. . 145 

from which the above account of his case is taken. In three of them, 
Ludwig, Lassus, and Schneider, there appears to have been at the most 
a diastasis ; the same is all that can be said, and with even less certainty, 
of Palletta's ; and those of Lazaretto, Pyl, and Harrison are worthless 
because of the lack of anatomical demonstration and even of symptoms 
upon which a diagnosis could be made. Darriste's case is erroneously 
quoted from a very brief note in the Archives GSnerales ; the original 
report (quoted above, p. 141) shows that it was a case of caries with sub- 
luxation. A case recently reported by Cole 1 of supposed occipito-atlantoid 
dislocation by muscular action, a sudden turning of the head, followed by 
reduction and recovery, was, I think, probably a dislocation of one of the 
lower vertebrae. 

The rarity of the occurrence is readily explained by the extent of the 
articular surfaces, the strength of the ligaments, and the extra-articular 
checks to the movement of the skull upon the atlas, the effect of which 
is to cause exaggerated movements of lateral or antero-posterior flexion 
of the head to be transmitted to the lower vertebrae. In the last of the 
three cases mentioned above (Milner's) the violence was very great, a fall 
from a height of seventy feet, and the mode of production of the dislo- 
cation is not known ; in the other two it was clearly a force acting from 
behind directly upon the atlas while the head was pressed backward, and 
in one of them, Bouisson's, the greater extent of the dislocation on one 
side than on the other was probably due to obliquity of the direction in 
which the force was exerted. 

In respect of the symptomatology and diagnosis nothing can be added 
to that found in the histories of these few cases, unless possibly the 
account given by Celsus may be accepted as having been based upon 
actual observation. To the sinking of the chin upon the chest, as 
noticed in Costes's case, he adds difficulty in swallowing and speaking 
(the former probably due to narrowing of the pharynx), and involuntary 
emissions. Possibly digital exploration of the pharynx would disclose 
the change in the relations of the occipital bone and atlas. 

If treatment is called for, the attempt to reduce should be made by 
steady traction on the head combined with such coaptative pressure upon 
it and the vertebrae as would be suggested by the character of the 
displacement. 

Dislocation of the Atlas (from the Axis). 

The articulation between the atlas and axis is composed not only of 
the two lateral articulations as in the other vertebrae, but also of that 
between the odontoid process and the anterior arch of the atlas. This 
process, which, genetically, is the separated body of the atlas that has 
united with the axis, is placed vertically behind the anterior arch of the 
atlas, and is firmly held in place by the strong transverse ligament of 
the atlas, by the two alar or cheek ligaments which pass from the base 
of the process to the occipital bone at the margin of the foramen magnum, 
and by the vertical band of the transverse ligament, the suspensory 

1 Cole : New York Medical Kecord, March 15, 1884. 
10 



146 DISLOCATION OF THE ATLAS. 

ligament, and the posterior occipito-axial ligament which overlies the 
others. 

Dislocation forward or backward is possible only after fracture of the 
odontoid process or rupture of the transverse ligament, or by the slip- 
ping of the process beneath the ligament. The number of cases of the 
injury demonstrated by autopsy is fairly large and contains examples of 
all three forms. In most of the reported cases the injury was a dias- 
tasis or incomplete separation of the articular surfaces, the atlas being 
displaced forward, and usually so inclined that its anterior arch lay in 
front of the body of the axis. If, in this change of place, the odontoid 
process is broken oif and accompanies the atlas, the probability of dan- 
gerous compression of the cord is somewhat lessened. The other forms 
that have been demonstrated are dislocations forward and backward of 
both articular surfaces ; dislocation forward on one side only (unilateral 
dislocation forward) has been observed only clinically. There is some 
reason to think that some of the obscure reported cases that ended in 
recovery may have been of the kind designated as " bilateral dislocation 
in opposite directions,' 1 that in which one articular surface is displaced 
forward and the opposite one backward, for experiment shows that this 
displacement can exist without causing compression of the medulla. A 
case observed by Sedillot probably was of this kind. ( Vide infra.) 

The following are examples of the rarer forms : 

Dislocation forward without rapture of the transverse ligament. — A 
man 1 sixty years old fell from a height of four or five metres, striking 
upon his head, and survived ten hours. The head was held in moderate 
dorsal flexion, but was freely movable. The odontoid process had passed 
under the transverse ligament, and compressed the medulla. The right 
alar ligament was torn, the left untorn. The articular surfaces of the 
atlas had moved forward upon, but had not entirely left, those of the 
axis. There was no fracture. 

A similar case is reported by Orton, 2 in which all the ligaments uniting 
the axis to the atlas and occipital bone were torn, but the transverse liga- 
ment was uninjured, and the odontoid process lay behind it compressing 
the cord. The injury was caused by a blow of the fist received obliquely 
from behind, on the angle of the jaw. Death was instantaneous. These 
two are the only positive examples of this injury. 

Dislocation backward. — A woman 3 sixty-eight years of age fell while 
descending a ladder, struck upon her forehead, and died instantly^ The 
atlas was dislocated backward on both sides, the anterior ligament detached, 
the capsular ligaments in front torn, the odontoid process broken at its 
base, and the posterior arch of the atlas broken on each side near the 
transverse process. The fracture of the atlas was thought to have been 
caused by its impact against the spinous process of the axis. 

There is no other reported case in which this variety has been demon- 
strated, post-mortem, but Malgaigne quotes from Ehrlich a supposed case 
which ended in recovery. The head was thrown backward and was very 

1 Journal de Chirurgie de Malgaigne, 1844, p. 370. 

2 Orton: Lancet, 1876, i. p. 853. 

3 Melchiori, quoted by Malgaigne, loc. cit., p. 333. 



DISLOCATION OF THE ATLAS. 147 

movable, and a firm prominence which was thought to be the axis, could 
be felt on the right side of the neck in front. There was loss of con- 
sciousness, and general paralysis. Reduction, accompanied by a distinct 
sound, was effected by traction upon the head, and pressure by the 
thumbs upon the prominence in the neck, while the fingers grasped the 
occiput. The head at once regained its solidity, and the paralysis dis- 
appeared. 

Bilateral dislocation in opposite directions. — Sedillot 1 reported the 
case of a girl who had suffered for some time with stiffness of the neck 
and deviation of the head to the left, although it could be turned to the 
right. The injury had been caused by a man who seized her by the 
head from behind and forcibly twisted it to the side toward which it 
remained deviated. She died seven weeks later, with increasing paral- 
ysis. The autopsy revealed a "dislocation of the atlas,'" the details of 
which are not given. The front of the odontoid process was rough, and 
the odontoid ligaments were torn and partly destroyed, but there was no 
pus. Only the anterior portion of the cord was softened. Blasius 
describes this case as one of bilateral dislocation in opposite directions ; 
although it was probably such, the description does not prove it. 

In the commoner forms of diastasis with inclination and displacement 
of the atlas forward, and in complete forward dislocation the transverse 
ligament is ruptured, or the odontoid process is broken off and accom- 
panies the atlas. In diastasis all the ligaments uniting the atlas to the 
axis are ruptured; in dislocation forward the ligaments of the posterior 
arch are sometimes untorn. In a case reported by Phillips, 2 the pos- 
terior arch of the atlas was broken off on each side and remained in 
place, while the anterior portion, including the articular surfaces and 
carrying with it the fractured odontoid process, was displaced so far 
forward and downward that it lay entirely in front of, and became united 
to the body of the axis. The patient survived forty-seven weeks and 
died of hydrothorax. The injury gave rise to no marked symptoms 
except persistent stiffness and pain in the neck, which were attributed 
during life to a strumous arthritis set up by the injury and treated by 
leeching and issues. 

I have met with no mention of injury to the vertebral arteries or veins. 

The spinal cord may be torn across in part or entirely, or crushed, 
or simply compressed. In double dislocation forward, it is most likely 
to escape injury if the odontoid process is broken off. On theoretical 
grounds, it is also thought not to be greatly endangered in bilateral dis- 
location in opposite directions. 

The cause has usually been a fall or blow upon the head. In forward 
dislocation, and in complete diastasis, the force has probably always been 
so exerted as to bend the head toward the breast; in partial diastasis, with 
rupture of the ligaments of only one side, the inclination must have been 
toward the opposite side. In two cases of suicide by hanging, in which 
complete diastasis was found, direct traction was probably aided by lateral 
flexion of the head. The cases in which the odontoid process has slipped 

1 Sedillot: Gazette Medicale, 1842, p. 770. 

2 Phillips: Med. Chirurgie Trans., vol. xx. p. 78. 



148 DISLOCATION OF THE ATLAS. 

backward under the untorn transverse ligament can be explained only 
on the supposition of forced flexion of the head and atlas forward and 
to one side. This supposition is supported in Orton's case by the direc- 
tion and nature of the violence that caused the injury. 

Unilateral dislocation or bilateral dislocation in opposite directions 
may be produced by exaggerated rotation of the head, as in Sedillot's 
case. The alleged efficiency of muscular action to produce these forms 
has not been demonstrated, and the comparatively frequent production of 
these forms of dislocation at lower points in the cervical spine in this 
manner suggests the probability of an error of diagnosis in the cases 
reported as occurring at this point, or between the atlas and skull, and 
ending in recovery. 

Symptoms. — In simple diastasis without displacement, and without 
injury of the cord, there may be no symptoms except pain and exag- 
gerated mobility of the head, and even the latter may be lacking because 
of spasmodic contraction of the muscles. If the diastasis is combined 
with displacement, and especially with fracture of the odontoid process, 
it cannot be distinguished from pure dislocation. In the latter the head 
may be very movable or rigidly fixed, and the movements of rotation 
which take place in the joints between the atlas and axis are abolished. 
In the common form, dislocation forward, the chin is depressed upon the 
chest, and a prominence may be felt at the back of the neck, below the 
occiput, formed by the spinous process of the axis. In the pharynx may 
be seen or felt the projecting anterior arch of the atlas. Pain is always 
present, and usually severe. Phillips's case, above quoted, is a marked 
exception in respect of pain, disability, and deformity. The nervous 
symptoms vary with the degree of injury to the cord. 

The prognosis, even accepting the cases of doubtful diagnosis followed 
by recovery, is very bad. Death may be caused immediately, or sud- 
denly at a later period by the shifting of the loosened bones and the 
consequent compression of the cord, or by the progress of the changes 
induced by the primary traumatism. 

Treatment. — Immediate reduction of the displacement and the preven- 
tion of its recurrence are imperative, if the former can be accomplished 
without such violence as would in itself endanger the life of the patient. 
Although Phillips's case furnishes proof that the persistence of the dis- 
placement is not necessarily incompatible with the prolongation of life 
and activity, and although this proof is supported by the survival in fair 
condition of several other patients who have received injuries at the upper 
part of the cervical spine, the exact nature of which was in doubt, but 
which were followed by permanent rigidity and deformity of the part, 
yet there can be no question, I think, of the propriety of making, or 
even of the obligation to make, cautious, well-considered attempts to 
correct the displacement. Even if dangerous pressure upon the cord 
has not at the time taken place, yet it is certain that the condition is full 
of the gravest risk. The displacement may gradually increase, as in 
Dubreuil's case, in which the chin did not touch the chest until the tenth 
or eleventh day, and death occurred suddenly on the seventeenth, or the 
fatal increment of displacement may be suddenly added by the relaxation 
of the spasmodically contracted muscles, or by an incautious movement 






DISLOCATIONS OF LOWER SIX CERVICAL VERTEBRAE. 149 

of the patient, or even of his attendants. This latter has occurred even 
after complete reduction, as in the following case which I quote in some 
detail because it will illustrate many of the prominent features of the 
injury: 

A man 1 fifty-eight years of age fell down a hill-side and remained all 
night upon the ground unconscious. In the morning he tried to walk 
and found himself "unsteady." Help came, and he was taken home. 
When seen by the reporter he was seated in a chair, his chin resting on 
his sternum, his head and neck rigidly fixed. He was conscious, not 
paralyzed, and complained of great pain in the neck. There was a 
marked prominence at the back of the neck below the occiput. 

By steady traction upon the sides of the head the displacement was 
completely reduced with a distinct snap and crepitus, and the pain was 
relieved. A week later he sat up in bed, and immediately fell back dead, 
with reproduction of the original deformity. 

The autopsy showed that the odontoid process had been broken off w T ith 
a portion of the body of the axis, and displaced forward with the atlas 
(the transverse ligament remaining intact) so far that the lateral articular 
surfaces were almost entirely separated. 

As it seems probable from the shape of the bones that complete disloca- 
tion forward, except in cases that are immediately fatal, is very rare, the 
traction upon the head should be directed somewhat backward, as well as 
upward, so as to avoid increase of the displacement, and may be com- 
bined with counter-pressure against the back of the neck. 

After reduction has been effected, and in cases of diastasis without 
displacement, the head and neck must be made immovable by suitable 
dressings. Certainly it would not be safe, even with the most tractable 
patients, to trust to simple rest in bed. In some cases a stiff leather 
collar has been sufficient, but I should prefer a plaster-of-Paris dressing, 
one that should envelop the head above the ears, the neck, or at least 
its posterior half, and the upper part of the chest, and that should be 
strengthened by strips of iron moulded to fit the parts, and included 
between its layers. 

Dislocations of the Lower Six Cervical Vertebrae. 

These are by far the most common of the dislocations of the spine, 
and the articulations between the fourth and fifth and between the fifth 
and sixth are the most frequently affected. The varieties that have been 
observed and verified are diastasis, bilateral dislocation forward, back- 
ward, and in opposite directions, and unilateral forward. Of these the 
bilateral forward and backward may be classed as dislocations by flexion, 
and the bilateral in opposite directions and the unilateral forward as dis- 
locations by abduction and rotation. The bilateral forward and the 
unilateral forward are the most common. The statistics of Blasius show 
that of 108 cases in which the exact nature of the injury was ascertained 
23 were diastases, 41 bilateral dislocations forward, 37 unilateral forward, 
4 bilateral in opposite directions, and 3 bilateral backward ; to the latter 

1 Dr. Gibson : Lancet, 1885, ii. p. 429. 



150 DISLOCATIONS OF LOWER SIX CERVICAL VERTEBRiE. 

to the latter may perhaps be added 8 others in which the diagnosis was 
not entirely beyond question. 

The positively demonstrated cases of bilateral dislocation backward 
are two reported by Porta and one by Stanley. The latter of the fifth 
cervical, in which the upper five vertebrae were firmly united to one 
another by bony fusion has been quoted above, p. 133. The dislocation 
was complete, the body Of the fifth vertebra resting upon the laminae and 
spinous process of the sixth. The injury was caused by a fall backward 
upon the head and back. Theoretically, it may be assumed that hyper- 
flexion forward of a vertebra, combined with direct pressure backward 
upon it, would produce this form of dislocation, for by the flexion a dias- 
tasis would be effected in which the. posterior and capsular ligaments 
would be torn, and then the direct pressure backward would rupture the 
intervertebral disk and produce the displacement. That the injury is 
rare notwithstanding the frequency of the occasions in which the head is 
bent forcibly forward is to be explained by the normal freedom of motion 
in this direction which allows the chin to be depressed upon the breast. 
In Stanley's case the ankylosis of the overlying vertebrae restricted this 
range, and in the movement forward the normal limit of movement of 
the fifth vertebra upon the sixth was promptly reached and the dislocating 
action begun. 

Of the four cases of bilateral dislocation in opposite directions I have 
not been able to examine the original reports in any. Possibly the one 
attributed to Malgaigne {Revue Med. Chirurg., 1853) is the same as the 
case described in his Luxations, p. 371, as unilateral forward ; if so, and 
if it is retained in the list, it would seem proper also to add Martelliere's 
case mentioned by Malgaigne upon the following page, 372, as resembling 
his own in the associated slight displacement backward of the opposite 
inferior articular process with rupture of the capsule. In Malgaigne's 
case there was also chipping of the lower border of the articular surface 
of the dislocated vertebra on the side of the principal dislocation with 
the production of a notch in which the upper edge of the underlying 
process was engaged. Similar chipping of the same border was found in 
Martelliere's case, but the articular process had passed completely beyond 
the underlying one and had descended in front of it to a distance of 
nearly one-quarter of an inch. This form is an exaggeration of the 
unilateral dislocation forward, and their causes and mode of production 
will therefore be considered together. 

In bilateral dislocation forward both inferior articular surfaces of the 
dislocated vertebra are carried forward beyond the anterior borders of the 
underlying ones, and the fixation is effected either by the dropping of 
the processes into the notches in front of the latter, or, if the movement 
forward is combined with anterior flexion, by the interlocking of the 
body of the upper vertebra with the projecting lateral borders of the 
upper surface of the under one. Blasius claims that this is effected 
almost as frequently by posterior as by anterior flexion, an opinion which 
it is not easy to accept. Flexion backward (hyperextension) of the neck 
is arrested, so far at least as the lower five vertebrae are concerned, by the 
contact with one another of the spinous processes, and, if continued upon 
these as a fulcrum and not modified by fracture, it would simply separate 



DISLOCATIONS OF LOWER SIX CERVICAL VERTEBRJE. 151 



Fig. 27. 



the bodies of the vertebrae vertically (diastasis) and would require the aid 
of another force acting backward or forward directly upon the vertebrae 
to dislocate them. Such a combination of forces would be furnished by 
violence acting upon a limited point on the back of the neck from behind 
forward, and instances of such are to be found in the records, as a fall 
in w 7 hich the back of the neck strikes against a sharp corner. 

In hyperflexion forward the fulcrum is found at the anterior border of 
the body of the vertebra, and the first effect, in like manner, is to produce 
diastasis with rupture of the posterior and capsular ligaments, and then as 
the projecting lip on the inferior anterior border 
of the body of the upper vertebra engages in front 
of the upper border of the lower one, and the force 
continues to act, not simply to flex but also to crowd 
the head directly down toward the chest, the body of 
the upper vertebra slips downward and forward, by 
which movement the articular surfaces are separated 
antero-posteriorly. Then if the neck is straightened 
the body of the vertebra may be raised to its original 
level, and yet the dislocation will be maintained by 
the interlocking of the articular processes. Under 
such circumstances there would be no angle in the 
direction of the neck, but only a depression in the 
nape and a projection in the pharynx corresponding 
to the body of the dislocated vertebra. 

Occasionally the spinous process with more or less 
of the adjoining laminae is broken off. The inter- 
vertebral disk is always torn, and so are usually 
the ligamenta flava and the interspinous ligament ; 
the longitudinal (anterior and posterior) ligaments 
are less frequently torn, often only stripped off, and thus by connecting the 
contiguous vertebrae they affect the posture of the head and neck. The 
spinal cord may be compressed or crushed, or may escape injury. 

As the articular surfaces are in some cases almost horizontal, the 
anterior borders being but slightly higher than the posterior ones, it is 
conceivable that the dislocation may be produced by direct violence acting 
upon the bone from behind forward, without the aid of either flexion or 
extension of the column. 

In unilateral dislocation forward 1 (dislocation by abduction and rota- 
tion) the articular surface on one side of the upper vertebra is carried 
upward and forward until its posterior edge has passed the anterior edge 
of the one with which it articulates. At the same time the spinous 
process moves from the median line toward the side of the dislocation, 
and the anterior surface of the body projects slightly in front of that of 
the underlying one. In short, the movement is one of rotation and 
abduction about the opposite articular surface as a centre, and by it the 
vertebral canal is but slio-htlv narrowed, and but little or no violence is 




Dislocation of the neck by 
flexion ; median section. 



1 Blasius (loc. cit., vol. 104, p. 82) found only one case of unilateral dislocation 
hackivard — of the sixth cervical — and even in it there was also fracture of the 
lamina and body of the seventh vertebra on the side of the dislocation. 



152 DISLOCATIONS OF LOWER SIX CERVICAL VERTEBRAE. 

done to the cord. The segment of the column above the dislocation is 
abducted, and forms with the lower part an angle or curve, the convexity 
of which is on the dislocated side. 



Fig. 28 



Fig. 29. 




Bilateral dislocation by flexion ; fourth 
cervical vertebra ; from behind. (Mal- 
gaigne.) 




Bilateral dislocation by flexion ; 
fourth cervical vertebra ; from the 
left side. (Malgaigne.) 



Fig. 30. 




Complete unilateral dislocation by rotation or abduction. 

The normal motion possible in the articulations of this region, is one 
in which rotation and abduction are combined in nearly equal propor- 
tions ; neither can take place without the other. The dislocation is 
produced by carrying the movement beyond its normal limits ; in other 
words, it is produced by any force which over-abducts or over-rotates the 
upper part of the column. This force may be an external one, or one 
developed by the muscles attached to the head. Of these dislocations by 
muscular action, Volker 1 collected fourteen more or less certain cases, and 



Volker: Deutsche Zeitschrift fiir Chir., 1876, vol. vi. p. 424. 



DISLOCATIONS OF LOWER SIX CERVICAL VERTEBRA. 153 

made them the basis of a careful study of the subject. Additional cases 
have since been reported. The movement which produces the lesion is 
a sudden turn of the head to one side, in which the action of the sterno- 
cleidomastoid far outweighs that of the rotators of the vertebrae them- 
selves, which are much too weak to rupture the ligaments that are found 
torn in this dislocation. If this movement is violent, ill regulated, if its 
momentum is unchecked by the antagonistic muscles, it carries the head 
beyond its normal limit, and produces the dislocation in exactly the same 
manner as if an external force had been applied to the head to turn it in 
the same direction. 

In diastasis the lesion consists essentially of more or less extensive 
rupture of the ligaments. It is the same in its forms, nature, and etiology 
as the other varieties, with the exception of the displacement of the bones 
and of the persistent change in the relations of the articular surfaces to 
each other ; the displacement is either entirely absent or is slight. It 
seems probable that in many of the cases described as diastases actual 
dislocation had been present at first, but had subsequently been reduced in 
the handling of the patient either before or after death, for the rupture 
of the ligaments is described as so extensive that the bones could be freely 
displaced upon each other in any direction. A singular instance of the 
production of a diastasis by muscular action is reported by Lasalle i 1 a 
crazy man, confined in a strait-jacket in a chair, jerked his head vio- 
lently backward and forward, became at once paralyzed, and died a few 
hours later. The autopsy disclosed a separation between the fifth and 
sixth cervical vertebrae, with rupture of the posterior ligament, the inter- 
spinous muscles, the ligamenta flava, and the intervertebral disk. 

Symptoms. — Unilateral dislocation fomoard. The posture of the head 
has varied so greatly in the reported cases that it is of no value as a 
symptom. Not only may the abduction of the upper segment of the 
column, which is necessary to the production of the dislocation, be almost 
entirely corrected by the sinking back of the articular process of the 
upper vertebra into the uotch of the lower one, but even if it persists it 
may be so far compensated for or obscured by flexion in the occipito- 
atloid and rotation in the atlanto-axial articulation, that it will not be 
recognized. The face is, however, usually turned away from the side on 
which the dislocation has taken place. A painful prominence, swelling, 
or rounding, can be recognized on the dislocated side ; it is due, accord- 
ing to Volker, to the angle created in the column, the slight projection 
of the transverse process, and the contracted condition of the muscles. 
Observers differ as to the condition of the muscles on the opposite side, 
some reporting them relaxed, others contracted. The deviation of the 
spinous process of the dislocated vertebra to the side of the dislocation, 
is a valuable sign when it can be recognized, but the depth at which the 
third, fourth, and fifth spinous processes are placed is such that their 
position cannot usually be determined, and while that of the second can 
always be felt, its deviation may be unrecognizable, because the position 
of the underlying ones with w T hich it must be compared remains unknown. 

1 Lasalle : Gaz. Medicale, 1841, p. 763. 



154 DISLOCATIONS OF LOWER SIX CERVICAL VEKTEBKJ. 

The projection of the body of the vertebra in the pharynx is sometimes 
recognizable by the finger introduced through the mouth. 

The last named three signs are diagnostic if fracture can be excluded, 
but as the last two are unrecognizable in many cases, the first, the exist- 
ence of a painful prominence on the side of the neck, is the one upon 
which the surgeon will usually have to depend. The differential diagnosis, 
at least in cases due to muscular action, is with muscular contraction 
(muscular caput obstipum) ; the following tabulation of the differential 
points is taken from Vogt. 1 Its statements must be accepted as true of 
only the majority of cases, not of all. 

Caput obstipum, muscular. Bight-sided Dislocation by rotation. Right side, 
contraction. 
Head abducted to the right. Face Face turned to the left. Head ab- 
turned to the right. ducted to the right only in complete 

dislocation with sinking of the articu- 
lar process of the upper vertebra deeply 
into the notch of the lower one. Other- 
wise, the abduction is variable. 



No change in the line of the spinous 
processes. 

Muscles variously contracted on the 
sides of the neck. No prominence to 
be felt. 



Spinous process of the dislocated 
vertebra deviated to the right. 

On the left, the muscles prominent 
and contracted, especially the trape- 
zius (?). On the right, by deep pressure 
through the contracted muscles a promi- 
nence can be felt. 



Abduction to the right easily in- Abduction to the left possible, but 

creased; to the left, impossible. Rota- painful ; to the right, impossible(?). 

tion to the left can be increased ; to the Rotation to the right impossible(?). 
right, impossible. 



No pain on pressure at any particular 
point of the neck. 



No change in the pharynx recogniz- 
able by palpation ; no difficulty in 
swallowing. 



Much pain produced by pressure on 
the prominence on the right side ; 
sometimes also on the left at the same 
level, and at the spinous process. 

Sometimes a recognizable prominence 
on the posterior wall of the pharynx ; 
sometimes difficulty in swallowing. 



Cases may occur, as they have occurred, in which the symptoms are 
so obscure that a diagnosis between dislocation by muscular action and 
muscular rheumatism cannot be positively made. Under such circum- 
stances the manipulations that would reduce a dislocation if it were 
present should be carefully made. If they reduce the deformity and 
relieve the symptoms they both establish the diagnosis and cure the 
patient. 

In bilateral dislocation forward the symptoms vary greatly. The 
head may be bent far forward toward the chest with marked prominence 
in the nape of the neck of the spinous process of the vertebra next below 
the dislocated one, or it may be bent backward or backward and to one 
side, with marked projection of the trachea and perhaps larynx, and irregu- 



1 Vogt: Moderne Orthopoedik, 2d ed., 1883, p. 77. 



DISLOCATIONS OF LOWER SIX CERVICAL VEETEBRJ. 155 



Fig. 31. 



larity in the outline of the front of the column recognizable by palpation 
through the soft parts. The head may be rigidly fixed, or, more rarely, 
freely movable. These differences depend partly on the position of the 
dislocated bone, the presence or ab- 
sence of associated fracture, and the 
extent of the injury to the connecting 
ligaments, partly on the direction and 
character of the dislocating force, and 
partly on the contraction or relaxa- 
tion of the muscles which control the 
position taken by the unaffected joints 
above the seat of injury. In the 
majority of cases the head is bent 
forward, and an angle with its apex 
directed backward is formed by the 
two segments above and below the 
dislocation. Attempts to move the 
head and pressure at the seat of in- 
jury are very painful. In these pa- 
tients the irregularity in the line of 
the transverse processes may also be 
recognized by the touch ; and if the 
dislocation is not too low the projec- 
tion of the body of the vertebra may 
be felt in the pharynx. 

Of the symptoms of bilateral dis- 
location backward nothing positive 
can be said. In most of the sup- 
posed cases the head has been bent 
backward, the face directed somewhat 

upward, the tissues of the front of the neck tense, and respiration and 
deglutition somewhat interfered with. 

Paralysis, partial or complete, is frequently observed. Its imme- 
diate importance, its urgency, as a symptom varies accordingly as the 
dislocated joint is above or below the point of exit of the phrenic nerve. 
The fourth cervical nerve, from which the phrenic mainly arises, though 
it receives a branch also from the third or fifth, leaves the vertebral canal 
through the foramen between the third and fourth vertebrae, but leaves 
the side of the cord at a somewhat higher point. A dislocation below 
the third cervical vertebra may cause paralysis of all the accessory 
muscles of respiration that act by raising the ribs, but, the diaphragm 
continuing to act, prolongation of life is possible. If, on the other hand, 
the dislocation is at a higher point, and the trunks going to form the 
phrenic nerve are injured or the cord is so compressed or torn that the 
integrity of the corresponding fibres within it is destroyed, or they are 
all cut off from the respiratory centre, then the diaphragm also, being 
no longer innervated by these nerves, immediately ceases to act, and 
the individual dies asphyxiated. In a few cases the threatening symp- 
toms have been instantly relieved by changing the position of the patient 
or by systematic reduction of the dislocation. In all such threatening 




Ayre' 



case of bilateral dislocation forward of 
the fifth cervical vertebra. 



156 DISLOCATIONS OF LOWER SIX CERVICAL VERTEBRA. 

cases and in those that have been immediately fatal the injury is, as a 
rule, at one of the upper joints. In the exceptions there have been 
associated injuries to which the death is to be attributed. 

If the paralysis is due to compression or laceration of the cord it may 
be complete of both motion and sensation below the point of injury, or it 
may involve only the motor nerves. It seems probable that the partial 
paralyses are due to pressure not upon the cord but upon a nerve trunk 
in the intervertebral foramen. 

Loss of control over the sphincters, incontinence of urine, and the 
other secondary symptoms of injury to the cord have been already con- 
sidered. 

Prognosis. — The mortality of dislocations of the lower six cervical 
vertebrae, excluding cases of diastasis, is, according to Blasius, fifty-six 
per cent., or, excluding all doubtful cases, sixty-six per cent. This esti- 
mate is open to the serious objection that it rests upon a principle of 
selection which views with suspicion every diagnosis that is not verified 
by post-mortem examination. Since there is good ground for this sus- 
picion in many cases and no better alternative method of selection is 
practicable, it seems better to assume that the percentage cannot at 
present be determined. According to the same statistics the mortality is 
greatest, 88.4 per cent., in the double dislocation forward, while that of 
the unilateral forward sinks to 34.9 per cent. In the fatal cases death, 
as a rule, comes promptly, within the first week. Suppuration has been 
observed about the seat of injury in cases that remained unreduced. 

Treatment. — In unilateral dislocation forward, at least in those pro- 
duced by muscular action, Volker says reduction is usually easy and free 
from danger. Mention has been made above of the case in which a boy 
reduced his own dislocation by resting his head and shoulder against a 
wall and pressing upon the prominence in the neck with his thumb. 

Simple traction upon the head, the counter-extension being made by 
the weight of the body, followed by rotation of the face toward the dis- 
located side has proved successful, but it seems better and is generally 
recommended that the articular process should be freed by still further 
abducting the head and upper segment of the column (away from the 
side of the dislocation), and then, when freed, should be rotated back- 
ward into place. If traction is used it should be made in the direction 
of the long axis of the upper segment, not in that of the lower one, for 
in the latter case the strain would come wholly or mainly upon the un- 
torn connections on the non-dislocated side and rather tend to depress 
the dislocated articular process still farther in front of the corresponding 
lower one than to raise it above it. 

Bilateral dislocations in opposite directions are to be classed with the 
preceding as dislocations by abduction and rotation, and treated in the 
same manner. Probably the differential diagnosis could not be made 
clinically. 

In bilateral dislocations forward it has been recommended by Hueter 
that the reduction should be made first on one side and then on the other 
by abduction and rotation, as if dealing with two unilateral dislocations 
forward. 

The methods that have been employed with success have combined 



DISLOCATIONS OF THE DOESAL VERTEBRAE. 157 

traction upon the head, either in the sitting or recumbent posture, with 
pressure upon the front and back of the neck at suitable points. 

After reduction the patient should be kept quiet for some time, and if 
reproduction of the dislocation is feared a retentive dressing should be 
applied. It must be rigid enough to prevent any flexion of the neck 
forward or back, and, after unilateral dislocation, should include the 
head so as to prevent rotation. Such a dressing might be conveniently 
made with plaster-of-Paris. 

Dislocations oe the Dorsal Vertebra. 

The cartilaginous surfaces of the articular processes in the dorsal region 
are placed more nearly in a vertical plane than those of the cervical ver- 
tebrae; the superior ones look backward and slightly upward and out- 
ward, the inferior ones, with the exception of those of the twelfth, look 
forward and slightly downward and inward ; the inferior ones of the 
twelfth are placed like those of the lumbar vertebrae and look outward 
and somewhat forward. This disposition does not in itself make dislo- 
cation to either side by rotation or direct dislocation backward with frac- 
ture difficult.; dislocation forward is made possible by flexion sufficient 
to raise the inferior articular processes of the upper vertebrae above the 
superior ones of the lower. Dislocation between the twelfth dorsal and 
first lumbar vertebrae seems to be much less favored by the relations of 
the processes, and yet this is the point in the combined dorsal and 
lumbar regions where dislocation is by far most common. Blasius (loc. 
cit., vol. 103, p. 4t>), collected twenty-two cases in which the character 
of the dislocation was demonstrated by autopsy ; of these one was of the 
third dorsal vertebrae, three of the fifth, one of the sixth, one of the 
ninth, three of the tenth, two of the eleventh, and eleven of the twelfth ; 
of the doubtful cases ten were of the twelfth, four of the eleventh, and 
one each of the fifth, eighth, and tenth. This greater frequency at the 
twelfth has been attributed to the greater normal mobility of this joint, 
but as the mobility is equally great, or even greater, between the lumbar 
vertebrae where dislocation is much more rare, this explanation is not 
sufficient. The explanation given by Chas. Bell 1 of the greater frequency 
of fractures at the same point seems equally applicable to dislocations ; 
it rests upon the combination of rigid and flexible segments in the column 
and finds the greatest frequency at the junction of such segments. This 
is supported by the experiments of Bonnet, who found that forced flexion 
of the dorso-lumbar column had its maximum effect between the eleventh 
dorsal and second lumbar, and especially at the first lumbar. Motion 
between the dorsal vertebrae is limited not only by their relations to each 
other but also by the attached ribs. 

The observed varieties are the bilateral forward and backward with 
about equal frequency, the bilateral in opposite directions, and the 
lateral. Of the latter there are only two demonstrated cases, Bell and 
Mohrenstein, twelfth dorsal, and even in these Blasius thinks the injury 
was primarily a unilateral dislocation forward or backward, which was 

1 Quoted in Fractures, p. 261. 



158 DISLOCATIONS OF THE DORSAL VERTEBRAE. 

followed by bodily lateral displacement. In the few cases in which the 
condition of the adjoining ribs is noted, these have been found sometimes 
dislocated and sometimes fractured not far from the column. The degree 
of injury to the cord varies with the character and extent of the dis- 
placement. Other pathological conditions have been considered above. 

The causes have been forcible flexion of the trunk forward and the 
direct action of great violence upon the back or side of the spinal column, 
as in the fall of a heavy object, or the passage of the wheel of a wagon 
across the body. 

The symptoms of the dislocation are found in recognizable changes in 
the position and relations of the dislocated vertebrae, especially in the 
prominence of its spinous process or of the underlying one, or in its 
lateral displacement, and in a deviation of the column which creates an 
angle at the seat of the dislocation, the apex of which is usually directed 
backward. In some cases it is noted that the articular processes of one 
or the other of the two adjoining vertebrae form prominences under the 
skin. 

Excessive mobility at the seat of dislocation has also been observed in 
most cases. 

Paralysis appears to be more common and more complete in the for- 
ward than in the backward dislocations, and in a few cases has disap- 
peared after reduction. 

The symptoms resemble so closely those of fracture that the differential 
diagnosis, in the absence of post-mortem examination, can rarely be made 
with certainty. The failure to obtain crepitation is no proof of the 
absence of fracture, and when present it may be due to the presence of 
an associated unimportant fracture. Reduction and the absence of a 
tendency to reproduction of the deformity are the best obtainable evidence 
that the injury was a dislocation. 

The prognosis, as regards either the preservation of life or the full 
restoration of function, is not favorable. The uncertainty of the diagnosis 
in most cases of survival and the comparative fewness of the cases deprive 
the percentages of value, and it can only be said that the injury seems 
more likely to prove fatal when it is situated in the upper part of the 
region than when in the lower, and that in quite a number of cases more 
or less complete recovery has followed. In one that has been under my 
observation for two years the patient, a girl fourteen years old, has been 
in good health although she remains completely paralyzed below the level 
of the breasts ; the injury appears to have been a diastasis at the fourth 
or fifth dorsal vertebra, and was caused by a fall down the narrow air- 
shaft of a tenement house from a height of about sixty feet. Such pro- 
longation of life has, however, seldom been reported. In other cases 
there has been a permanent deformity or an abnormal mobility at the 
injured point. 

Treatment. — Reduction, by extension and counter-extension at the 
hips and shoulders, has been tried, and sometimes with success. If it is 
obtained the patient must be kept absolutely recumbent for several weeks, 
and preferably with the trunk enveloped in a plaster-of-Paris dressing, 
and the same measures should be employed even when reduction has not 



DISLOCATIONS OF THE LUMBAR VERTEBKJ. 159 

been effected, in order to favor the consolidation of the bones in their 
new positions. 

It seems not improbable that the knife may yet be resorted to with 
advantage to expose the dislocated bone and enable the surgeon to act 
with better knowledge of the actual displacement and of the difficulties 
to be overcome. I believe, however, that such an operation should not 
be done until after the soft parts have had time to recover from the lacer- 
ation of the original traumatism. 

Dislocations of the Lumbar Vertebra. 

The possibility of the occurrence of pure dislocation of the lumbar 
vertebrae, which has been long in doubt because of the close interlocking 
of the processes and the strength of the ligaments, is proved by two 
cases collected by Blasius and also, it may be said, by two others in 
which there was present associated but unimportant fracture of some of 
the processes. The first two cases are those of Curling 1 and Porta. 2 

Curling presented a specimen preserved in the London Hospital 
Museum : the intervertebral disk between the third and fourth lumbar 
vertebrae was destroyed, with slight splintering of the edge of the bone 
at one or two places ; the body of the third projected nearly half an inch 
in front of that of the fourth, and the articular processes of the two 
bones were separated to the same distance ; the ligaments connecting the 
laminae and the spinous processes were stretched but not materially torn. 

The other two cases are those of Keig 3 and Cloquet. 4 In the former 
a sailor twenty-three years old was crushed under a heavy iron cylinder 
which fell across his back. The second lumbar vertebra was displaced 
backward seven lines, the upper articular process of the third becoming 
lodged in the notch of the second ; the tip of the right lower articular 
process of the second was broken off but not separated from the rest ; 
the left transverse processes of the first and second vertebrae were broken 
off (by muscular action, it was thought), and the spinous processes of the 
ninth, tenth, and eleventh dorsal vertebrae and the left eleventh and 
twelfth ribs were broken. The right sacro-lumbalis muscle was com- 
pletely divided transversely, and the liver and spleen ruptured. 

In another case Porta found at the autopsy a pure diastasis between 
the third and fourth lumbar vertebrae, the bones being separated a few 
lines without lateral or antero-posterior displacement, and all the liga- 
ments being torn ; the spinous process of the third was broken at its 
base. 

The conditions which so effectually oppose dislocation witlr or without 
fracture are the great breadth, thickness, and elasticity of the interverte- 
bral disks, the large masses of muscle that lie on each side of the spinous 
processes, and the arrangement of the articular processes by which those 
of each upper vertebra are received between those of the next lower and 

1 Curling: London Hospital Beports, vol. 3, p. 355. 

2 Quoted by Blasius: Loc. cit., vol. 103, p. 55. 

3 Keig: Schmidt's Jahrbuch, vol. 107, p. 69. (Blasius writes the name Keli.) 
* Blasius : Loc. cit., from Journal des Difformites, vol. 1, p. 453. 



160 DISLOCATIONS OF THE LUMBAR VERTEBRJ. 

are thus absolutely prevented from moving laterally or from being 
separated by lateral flexion without fracture of one or the other. 

In the eighteen cases collected by Blasius the dislocation was most 
frequently of the first vertebra, next of the second, and then of the 
third ; the fourth and fifth were each dislocated once. 

In the cases uncomplicated by fracture the only varieties observed were 
dislocations forward and backward (dislocation by flexion) ; in the others 
there were examples also of the unilateral and bilateral (dislocation by 
rotation). 

The symptoms are irregularity in the line of the spinous processes, 
local pain, disability, and more or less complete paralysis of the parts 
below. As the spinal cord is replaced throughout the greater part of 
this section by nerve trunks, the cauda equina, which less completely fill 
the canal, the paralysis is less likely to be complete than when the injury 
is at a higher point, and it is also more easily recovered from if the dis- 
placement is corrected. The extreme attitudes described in some of the 
cases, as in Larrey's, in which the head rested on the knees, must be 
ascribed either to associated fracture or, more probably, to general 
muscular relaxation. Abnormal mobility or immobility of the entire 
column or at the injured point is dependent upon conditions already 
discussed in connection with dislocations at other points. 

The prognosis is more favorable than in dislocations of the dorsal or 
cervical regions, presumably because of the usual absence of injury to 
the cord, and the less extent of the paralysis ; and, while many of the 
cases have proved promptly fatal, death has usually been due to associated 
injuries. 

Treatment. — In backward dislocation reduction appears not to have 
been difficult; it has been obtained by pressure upon the projecting spinous 
process, with or without forcible extension of the column. In a case 
reported by Harrison, 1 dislocation backward of the third lumbar vertebra, 
reduction was obtained with the aid of anaesthesia by extension and 
counter-extension, combined with moderate pressure upon the spinous 
process, while the patient was lying upon his back. The paralysis began 
to diminish on the following day, and complete recovery followed, although 
a slight projection in the line of the column persisted. A plaster-of- 
Paris jacket was worn for four and a half months. 

Possibly the plan recommended by some of the older surgeons of com- 
bining flexion forward with extension, would be necessary or useful in 
some cases. It could be effected by placing the patient on his belly 
across the side of a barrel, or by raising him on a cloth passed under his 
belly. 

1 Harrison: Lancet, 1885, ii. p. 114 



CHAPTEE XIII. 

DISLOCATIONS OF THE STERNUM. 

Under this title are included only dislocations of the normal divisions 
of the sternum from one another, not those of the sternum from the 
clavicles or from the cartilages of the ribs ; they are those of the body 
from the manubrium, and of the ensiform process from the body. 

Dislocations of the body from the manubrium. — The manubrium, con- 
stituting nearly the upper third of the sternum, is united to the second 
piece, the body, by a layer of interposed cartilage, sometimes hyaline, 
sometimes more or less distinctly fibrous, and sometimes containing a 
central synovial sac of variable size. Henle speaks of this central sac 
as of rare occurrence ; Maisonneuve and Brinton found it in about two- 
thirds of the cases examined. Ossification of the band occasionally 
takes place in advanced life ; the earliest age at which it has been 
observed is thirty-four years. 

The second costal cartilage articulates with both these segments of the 
sternum at their junction. Although this division of the sternum into 
segments was described by the anatomists, no account thereof appears to 
have been taken by surgeons until, in 1842, Maisonneuve 1 read before 
the Academie de Medecine in Paris, a paper in which he called attention 
to the anatomical divisions of this bone, and reported two cases of dislo- 
cation of the body from the manubrium which had come under his 
observation, and in which he had made the autopsies. Earlier records 
show several cases which were doubtless dislocations, but Maisonneuve 
was the first to separate them from the class of fractures and apply this 
name to them. 

The injury is not a common one, even if allowance is made for the 
probable description of some as fractures. Malgaigne, in 1855, could 
collect only ten examples, although he included in the list several of the 
older cases reported as fractures ; Ancelet 2 collected sixteen cases of 
all kinds. Brinton 3 thirteen of dislocation forward, and added one of his 
own. Gurlt, 4 in his table of fractures and diastases of the sternum, has 
twenty-nine cases classified as diastasis between the first and second pieces, 
and three between the second and third. Adding to these those quoted 
by Ancelet, Brinton, and Servier, 5 the list is increased to more than fortv. 
Only one of the patients was a woman, and the ages ranged from thirteen 
to more than sixty-five years. 

In sixteen the body was completely dislocated forward and upward 

1 Maisonneuve : Arch. cen. de Med., 1843, vol. 14, p. 249. 

2 Ancelet: Gazette des Hopitaux, 1863, p. 257. 

3 Brinton : Amer. Journ. of Med. Sci., July, 1867, p. 39. 

4 Gurlt: Die Knochenbruche, 1862, vol. 2, p. 31. 

5 Servier: Diet. Encyclopedique, 1883, art. Sternum. 

11 



162 DISLOCATIONS OF THE STERNUM. 

upon the manubrium, in three or four backward ; in two the dislocation 
was incomplete forward, and in one the two segments were separated 
longitudinally. 

Causes. — The injury has been produced by direct and indirect violence, 
and, possibly, in- one or two cases, by muscular action. Guines,' in the 
report of a case of tetanus in a boy thirteen years old, states that on the 
seventh day he found the breast elevated, all the false ribs displaced and 
carried upward, the sternum bent at the junction of the first and second 
pieces, and forming with the ensiform process an eminence three inches 
high. The pectoral muscles w T ere forcibly contracted, while those of the 
abdomen were, if not in their natural condition, at least much relaxed 
(compared with their previous condition). On the eighteenth day, the 
tetanus having ceased, it is noted that the deformity of the breast per- 
sisted. I understand this to mean that there was an angular displacement 
at the junction of the first and second pieces, the apex being directed 
backward, and the ensiform process distant three inches further than 
usual from the spme. 

In two other cases muscular action may possibly have been the deter- 
mining cause, but the mode of production is obscure ; in one of them 
(Drache, quoted by Malgaigne), a young man fell into a cellar with some 
falling timber, which rested upon his chest ; while striving to free himself 
he felt a snap in the region of the sternum, and the dislocation was 
thought to have been then produced. In the other (Ancelet), a boy 
thirteen years old was exercising on parallel bars with his chest bent 
forward ; his feet unexpectedly touched the ground, and a forward dis- 
location, complete on only the left side, w T as produced. 

In the case of longitudinal separation (Aurran and David), the patient 
fell from a height of fifty feet, striking on his back across a low wall so 
that his head was on one side and his legs on the other. He received at 
the same time a fracture of the spinous processes of the last two dorsal 
vertebrae, and the dislocation (a diastasis) seems therefore to have been 
produced by hyper-dorsal flexion of the spinal column, by which the two 
segments of the sternum were pulled apart. The case seems, to some 
extent, to confirm the theory of the possibility of dislocation by muscular 
action. The patient recovered. 

In three cases a forward dislocation was caused by violence received 
directly upon the front of the chest, presumably upon the manubrium. 
One patient (Aurran) fell with a ladder, striking his chest against one of 
the rungs ; another (Malgaigne) fell against the gunwale of a boat ; the 
third (Fremey 2 ) was struck and killed by the pole of a wagon. Drache's 
case also is sometimes quoted as an example of direct violence, and so 
perhaps may be Richet's, 3 in which some boxes of soap fell upon a man, 
and caused a dislocation backward of the body upon the manubrium. 
Reid's patient was kicked by a mule ; the direction of the displacement 
is not mentioned. 

In Duverney's 4 patient the injury was compound, and was caused by 



1 Guines: Arch. gen. de Med., 1829, vol. 19, p. 396. 

2 Fremey: Bull de la Soc. Anatomique, 1868, vol. xiii. p. ua. 

3 Kichet, repotted by Siredy in Bull, de la Soc. Anat., 1857, vol. ii 

4 Duverney : Maladies des Os, 1751, vol. i. p. 235. 



i. p. 41' 

"" p. 305. 



DISLOCATIONS OF THE STERNUM. 163 

the forcible compression of the sides of the chest by a falling stone, the 
second piece being thrust forward (see Fractures, p.. 300) ; and in Pitha's 1 
it was caused by similar lateral compression between the buffers of two 
railway cars. 

In most of the others the injury was caused by a fall from a height, 
by which the trunk was probably bent forcibly forward, as shown in 
several of them by associated fracture of the cervical or dorsal vertebrae. 
The mode of production in these cases appears to be similar to that by 
lateral compression of the ribs ; the first and second ribs being shorter 
and more rigid than the others, the manubrium remains fixed, while the 
second piece is pushed forward and upward by the other ribs that articu- 
late with it and which are themselves pressed forward by the flexion of 
the spine. Servier demonstrated this action upon the cadaver by exposing 
the sternum and costal cartilages, dividing the third, fourth, and fifth of 
the latter, and then throwing the body backward from a sitting position 
so as to strike upon its shoulders on the floor ; the ends of the ribs could 
be seen to spring forward and inward. 

Pathology. — In the common form, dislocation of the second piece for- 
ward and upward, the bones override, sometimes as much as an inch ; 
the anterior fibrous layer lining the bone is torn, the posterior one 
stripped from the second piece. In Brinton's case the body was twisted 
somewhat obliquely downward toward the right side. The upper end of 
the body may also be so inclined forward that it is separated from the 
anterior surface of the manubrium and rests only against its upper edge. 
The second costal cartilages almost invariably remain in contact with the 
manubrium. Sometimes the third and fourth have been broken. 

In two cases the dislocation has been incomplete, Nelaton's and the . 
boy reported by Ancelet who received his injury while exercising on 
parallel bars ; in the latter the body was turned about its longitudinal 
axis so that its left upper corner was elevated above the manubrium and 
the second costal cartilage to a distance fully equal to the thickness of 
the bone, while its right upper corner remained in place. In one case 
(Duverney) the dislocation was compound. 

The dislocations of the body backward furnish two autopsies. Sabatier's 
patient 2 was an elderly man who, after having been beaten with the fists, 
was thrown into a ditch thirty feet deep ; he survived for a week. The 
body of the sternum was displaced 2.8 cm. upward behind the manu- 
brium ; there was a large extravasation of blood under the skin and in 
the substance of the right lung, which was extensively bound down by 
old adhesions. 

Richet's patient, twenty-seven years old, was thrown down upon his 
back by some heavy boxes that fell from a wagon upon his chest and 
caused many associated injuries; he died of pyaemia on the twenty-second 
day. The body of the sternum was displaced backward and slightly 
upward behind the manubrium : the second costal cartilage on the left 
side remained attached to the body, that of the right side was separated 
from both body and manubrium, and its end was free in an abscess that 
bathed the dislocation. There was a complete transverse fracture of the 

1 Gurlt: Loc. cit. , p. 225. 2 Gurlt: Loc. cit., p. 275. 



164 DISLOCATIONS OF THE STERNUM. 

manubrium half an inch above its lower end, and a fracture of the body 
without displacement at the level of the articulation of the fourth costal 
cartilages. There was a compound fracture of the left leg, and simple 
fractures of the left third and fourth ribs and of the right radius. 

The complications have been numerous and varied : fractures of the 
cervical and dorsal vertebrae, of the ribs, costal cartilages, pelvis, thighs, 
and legs, rupture of the adherent lung, rupture of the lungs and heart 
(Duverney). 

Symptoms. — In the severe cases — those complicated by other injuries, 
especially of the spinal column and thoracic viscera — the general symp- 
toms due to the dislocation may be masked or increased by those of the 
other lesions ; in general terms, the rational symptoms in forward dislo- 
cation are more or less transient oppression of breathing and sharp pain 
at the seat of injury, increased by pressure or by movements of the body 
or head. 

The neck and trunk are bent forward, the lower ribs appear prominent, 
and the upper ones depressed. The anterior surface of the sternum pre- 
sents a well-marked elevation at the level of or just below the first inter- 
costal space, which has a sharp, well-defined upper margin rising directly 
from the manubrium and is continuous below with the body of the sternum. 
The absence of the second costal cartilages from the upper corners of the 
body makes it possible to recognize with the finger the shallow, saucer- 
like depression at these points with which they articulate. The recog- 
nition of these depressions, or the distance of the upper edge of the pro- 
jection from the line of the third ribs, will enable the surgeon to dis- 
tinguish a dislocation from a fracture of the body ; and the presence of 
the second costal cartilages below the upper edge of the projection will 
indicate a fracture of the manubrium. 

The prognosis is grave ; more than half the patients have died of their 
injuries, though doubtless the fatal result is to be attributed in most of 
the cases to the associated lesions. In the cases that have survived a 
failure to effect reduction has not led to any disability ; one of the patients 
in the list had borne his unreduced dislocation for fifteen years without 
inconvenience. Stetter 1 mentions, without giving the reference, a case 
observed by Audic of habitual dislocation backward (or of the manu- 
brium forward) which recurred every time the patient rose from the 
recumbent posture without supporting his head. 

Treatment. — Reduction is to be made by bending the trunk backward 
and making pressure upon the projecting piece of the sternum. The 
patient should be placed upon his back on a firm cushion or on a table 
with his head and shoulders projecting beyond its end, and then the 
head and neck should be drawn backward, and counter-extension made 
on the pelvis. It is recommended also that in dislocation backward the 
patient should be encouraged to make full inspirations. 

After reduction is made a body bandage, or, better, a broad strip of 
adhesive plaster should be placed around the chest. 

In case of failure to reduce by these or other simple means, resort 

1 Stetter : Compend von den Luxationen, 1886, p. 19. 



DISLOCATION OF THE ENSIFOBM PROCESS. 165 

should not be had to cutting operations unless grave indications due to 
pressure upon the thoracic organs should exist. 

Pathological dislocations. — To the three examples of this kind quoted 
by Malgaigne, Servier has added a fourth. They are, in brief, as follows : 

1. Beauchene. A medical student twenty-three years old, who suffered 
from almost continuous pain at the middle of the sternum and from osteo- 
copic pains in the lower limbs, had acquired the habit of pressing frequently 
and forcibly with his hand upon the sternum ; as a result, the first two 
pieces of the bone became partly displaced and flexed upon each other 
so as to form a very marked projection forward. When the patient ro- 
tated his thorax to one side or the other the two pieces moved upon each 
other with pain and crepitation. Anti-syphilitic remedies relieved the 
pains in the limbs, but those in the sternum persisted. Malgaigne 
thought the affection was a simple arthritis of the joint, and says he had 
himself several times suffered in like manner, and had found relief in 
pressure upon the sternum which prevented it from moving during in- 
spiration. 

2. A watchmaker, who worked seated and bent forward, found that 
the position caused a disagreeable sensation at the upper part of the 
sternum and some difficulty in breathing, and he noticed when he 
straightened himself a singular creaking at this point which appeared to 
be caused by the sliding of the manubrium in front of the body of the 
bone. He abandoned his occupation and the subluxation gradually dis- 
appeared. Ten years later, when he was thirty-eight years old, it 
suddenly reappeared, but had not since recurred. 

3. Graves. A medical student nineteen years old, who some years 
before had often suffered from serious inflammation of the chest, but 
whose health was completely reestablished, could push backward with his 
hand the body of the sternum and the corresponding costal cartilages to 
a depth of two inches. The upper margin of the depression was two 
inches below the upper border of the sternum ; the latter margins cor- 
responded to the line of union between the ribs and their cartilages. The 
movable piece was much softened. 

4. Bourneville 1 observed in a patient nineteen years old suffering from 
generalized tubercular disease a fluctuating prominence at the level of 
the junction of the first two pieces of the sternum, the body appearing to 
be subluxated forward ; reduction was accompanied by slight crepitation. 
The autopsy showed a separation between the two pieces of one centi- 
metre, with distention of the anterior ligament due to thick yellow pus 
that filled the joint between the two pieces and the second costal cartilages. 

Dislocation of the Ensiform Process. 

Of this injury, referred to by many of the earlier writers as a possi- 
bility, only five or six more or less well authenticated cases are on 
record. They are those of Martin and Billard, quoted by Malgaigne, 

1 Bull, de la Soc. Anatomique, 1869, vol. 14, p. 56. 



166 DISLOCATION OF THE ENSIFORM PROCESS. 

Polaillon, 1 Gallez quoted by Servier, and Hamilton. 2 In addition may 
be mentioned the reference made by Malgaigne to an example observed 
in a newborn child by Seger, and that to one similar to Polaillon's (as 
quoted by Mauriceau) in the discussion on his case. 

Polaillon's patient was a woman thirty-five years old, and her injury 
was caused apparently by tight lacing to conceal the enlargement of 
pregnancy ; all the others were males, and their injuries were caused by 
blows received upon the epigastrium; their ages were eighteen, nineteen, 
twenty-eight, and fifty-three years. 

No autopsy was had in any case, and in Polaillon's alone is the con- 
dition described with sufficient detail to make it reasonably certain that 
the separation took place at the line of union between the process and 
the body of the sternum ; the others may have been fractures of the 
process itself. In Polaillon's the base of the process was displaced back- 
ward, and the point looked directly forward. In Hamilton's, first seen by 
him twelve years after the accident, the cartilage was " bent at right 
angles with the sternum, pointing directly toward the spine." In the 
other cases the character of the displacement is not fully described, but 
apparently the apex of the process was directed backward in most. 

In three cases the most prominent symptom was persistent vomiting, 
which in one (Hamilton's) recurred every five or six days for two years 
and then ceased spontaneously, in another (Martin) was relieved by 
grasping the process with the fingers and drawing it forward into place, 
and in a third (Billard), after it had lasted a month and threatened to 
prove fatal, was relieved by drawing the process forward by means of a 
blunt hook introduced below it through an incision. Polaillon's patient 
suffered sharp pain, which was excited by the pressure of the clothing 
and the ingestion of food, and was extremely severe during delivery ; 
reduction was impossible, and after a time the inconvenience caused by 
it ceased. In Grallez's case the prominence could be reduced and repro- 
duced with a click by manipulation ; the patient suffered only local pain 
and was promptly cured by reduction maintained by the aid of a small 
compress fixed over the process by means of adhesive plaster. 

1 Polaillon: Bull, de la Soc. de Chirurgie, 1877, p. 9. 

2 Hamilton : Fractures and Dislocations, 6th ed., p. 182. The account leaves it 
uncertain whether this was deemed a fracture or a dislocation. 









CHAPTEE XIV. 



DISLOCATIONS OF THE RIBS AND THE COSTAL CARTILAGES. 

Under this title are included dislocations of the ribs at their juncture 
with the vertebrae, of the ribs from the costal cartilages, of the cartilages 
from the sternum, and of the cartilages of some of the lower ribs from 
one another. 

The head of each rib articulates with the bodies of one or two vertebrae 
by a true joint containing one or two synovial sacs and strengthened by 
firm ligaments ; the tubercle and neck of each rib, except the eleventh 
and twelfth, are united to the transverse process of the corresponding 
vertebra by a synovial joint and ligaments and to the transverse process 
of the vertebra next above by a longer ligament. The union between 
each rib and its costal cartilage is direct, without a synovial sac, and is 
strengthened on the anterior surface by the periosteum. The articula- 
tions between the costal cartilages and the sternum are, with the exception 
of the first, true synovial joints, sometimes double, surrounded by a 
capsule which is strengthened in front and behind to form the anterior 
and posterior ligaments. The seventh rib is the lowest that articulates 
with the sternum. The fifth, sixth, seventh, eighth, and ninth costal 
cartilages are united with one another for a short distance on their con- 
tiguous margins by true synovial joints formed by slight projections on 
their margins and surrounded by capsules which are strengthened by 
fibres derived from the anterior intercostal aponeuroses. 

Dislocation of the Head of the Rib. (Luxatio Costo- 
vertebralis.) 

The earlier writers described three forms of dislocation of the head of 
the rib as possible, upward, downward, and inward, but their descriptions 
appear to have been based exclusively upon their notions of what was 
anatomically possible, and not to have been supported by knowledge of 
the actual occurrence of any of the forms. The first recorded case, and 
that a doubtful one, was reported in 1753 to the Academie de Chirurgie 
by Buttet. His patient was a man fifty-five years old who had been run 
over by a wagon ; he was so fat, and the swelling was so great that the 
outlines of the ribs could not be traced, and the diagnosis was based on 
the fact that when pressure was, made upon the front of the chest the 
sixth rib on the right side could be felt to move with a very distinct, 
audible click which, moreover, was reproduced whenever the patient made 
a movement of his trunk. 

The next case was Hankel's 1 in 1834 : a young man fell into a clay- 



1 Hankel: Gazette Medicale, 1834, p. 187. 



168 DISLOCATION OF THE HEAD OF THE EIB. 

pit and received an injury in the lower dorsal region; he died on the 
fifteenth day, and the autopsy showed fractures of the eleventh dorsal 
vertebra and of the twelfth rib on each side and a dislocation of the 
eleventh left rib. • 

During the next following six years six additional cases were reported, 
and the list has not since been added to except by Webster's case, the 
date of occurrence of which is not known but is probably earlier than 
that of the others. 

M. Webster, 1 when examining the body of a patient who had died of 
fever, found the head of the seventh rib thrown upon the front part of 
the corresponding vertebra and there ankylosed. He learned that the 
individual, several years before, had been thrown from his horse across 
a gate and was supposed to have broken a rib. 

Boudet, 2 in 1839, reported the case of a man thirty-two years old who 
had been instantly killed by a fall from a height of ninety feet. The head of 
the fourth rib on the left side had been dislocated, without fracture, for- 
ward and inward through the pleura and into the lung ; the corresponding 
transverse process was broken. 

Alcock 3 reported the case of a man who by a fall from a roof received 
injuries of which he died on the fifteenth day. The laminae of the sixth 
and seventh dorsal vertebrae were broken, and the spinous processes 
driven into the vertebral canal ; the sixth, the seventh, and eighth ribs 
were fractured, and " tw T o of them had their heads dislocated from their 
articulation with the transverse processes." The case is quoted by 
Malgaigne and subsequent writers from an abstract in the Gazette des 
Hopitaux, and their description reads " their heads were entirely 
expelled from their articular cavities." 

On the page (586) in the London Medical Gazette preceding that in 
which the original account is found, Alcock reports another case not 
mentioned by Malgaigne or those who have followed him : a soldier 
received a gunshot wound in the back, the ball entering three inches 
from the spinous processes and lodging in the body of the twelfth dorsal 
vertebra. The eleventh rib was found to have been fractured between 
the neck and the angle, and " the head of the twelfth rib was dislocated 
on the body of the succeeding vertebra." 

Finally, three cases were published in February and March, 1841, in 
the Dublin Medical Press, those of Kennedy, Dunne, and Finnecane. 4 
Kennedy's patient was a man twenty years old who fell from a falling- 
platform at a horse race ; be complained especially of pain in the lumbar 
region which was the seat of a large ecchymosis. On examination the 
surgeons found a distinct depression at the site of the heads of the 
eleventh and twelfth ribs, and pressure made upon their anterior ends 
caused the other ends distinctly to move without crepitation. The 
patient recovered in three weeks. The diagnosis was dislocation of the 
last two ribs downward and forward. 

1 Webster : Cooper on Dislocations and Fractures, Am. Ed., 1844, p. 450. 

2 Boudet: Bull, de la Soc. Anatomique, 1839, vol. 14, p 104. 

3 Alcock : London Med. Gazette, 1838-39, vol. 2, p. 587. 
i Abstracts in the Gazette Medicale, 1841, p. 410. 






SEPARATION OF RIBS FROM COSTAL CARTILAGES. 169 

Dunne's patient was a lad eleven years old who received a blow upon 
the back ; he became paraplegic on the seventh day and was brought to the 
hospital on the ninth, when a swelling one inch broad and three-quarters inch 
high was found extending along the left of the spinal column in a position 
corresponding to the heads and necks of the last three or four ribs ; the 
tenth and eleventh ribs appeared to be depressed. An abscess formed 
and was opened, and the boy died on the sixteenth day. The tenth and 
eleventh ribs were found to be dislocated forward, the former completely, 
the latter incompletely. The costo-transverse ligaments of the tenth rib 
were completely ruptured, and the displacement was such that the finger 
could be passed between the head of the rib and the corresponding 
articular surface on the body of the vertebra. 

Finnecane s case was that of a girl fifteen years old who was killed by 
the fall of the roof of a burning house in which she was lying ill of a 
fever. She was found dead on her knees beside the bed, one beam 
having fallen upon her head, and another across her loins. The last two 
ribs on the left side were found dislocated forward on the bodies of the 
vertebrae, and the costo-vertebral and costo-transverse ligaments ruptured. 

It appears from these scanty records that the lower ribs, especially the 
last two, are the ones most exposed to be dislocated, and that the cause 
is direct violence received from behind. The only form verified by 
autopsy is dislocation forward, and in only one case (Kennedy) was it 
thought that the rib w r as dislocated downward as well as forward. 

The great mortality in the cases, six out of nine, is of course to be 
attributed to the associated lesions ; there is no reason to think that the 
simple dislocation of the head of the rib would of itself be dangerous 
unless in its displacement it should injure adjoining important parts, as 
it did indeed in Boudet's case, in which it perforated the lung. 

The treatment employed in the cases that recovered was very simple, 
a body bandage with, in one case, a compress over the anterior ends of 
the ribs, an addition which it is permitted to suppose was not of impor- 
tance. 

Separation of the Ribs from the Costal Cartilages. 
(Luxatio Chondro-costalis.) 

Of this injury there are only five, possibly six, examples on record, 
and in only one of these was the condition demonstrated by autopsy. 
Three of the cases are described by Malgaigne, and the fourth, of which 
he quotes a brief mention by Samuel Cooper, is in all probability the 
well-known case of Charles Bell. Of the fifth case our only knowledge 
is through the description of the specimen presented without history to 
the Societe Anatomique by Carbonell. 1 It showed a separation of the 
second, third, and fourth cartilages from the ribs, with fracture of the 
ossified union between the first rib and the sternum and of the fifth costal 
cartilage one centimetre from its outer end ; all five ribs were also broken 
at their angles, and the right bronchus was torn away from the trachea. 

Chaussier's 2 patient was an officer forty-eight years old who had long 

1 Carbonell: Bull, de la Soc. Anatomique, 1865, p. 17. 

2 Chaussier : Bull, de la Faculte, 1814, p. 50, quoted by Malgaigne. 



170 DISLOCATION OF COSTAL CARTILAGES. 

suffered with a cough and had thereby produced a hernia of the lung 
between the eighth and ninth ribs on the left side and another between 
the seventh and eighth ribs on the right side at the level of their junction 
with the cartilages, accompanied by a separation between the seventh rib 
and its cartilage on the right, and between the eighth and its cartilage 
on the left ; at each of these points the rib was movable with crepitation. 

Bouisson's and Chas. Bell's cases have been quoted in the volume on 
Fractures, p. 321. In the remaining case, De Kimpe, 1 the patient was 
thrown from his horse, and struck his chest against a milestone ; the 
fifth costal cartilage on the left side was depressed so that the rib overrode 
it and projected under the skin. The displacement could be corrected 
by a full inspiration, but recurred on expiration. A tight starch bandage 
was worn for three weeks, and then union was found to have taken place 
with a displacement backward of the cartilage equal to about one-third 
its thickness. 

The possible sixth case is Monteggia's, 2 a separation of the second and 
third costal cartilages in a very emaciated man seventy years old, in 
consequence of a violent attack of coughing. Grurlt says : " Monteggia 
declares expressly that it was not a fracture of the cartilage but a sepa- 
ration of the epiphysis," by which, of course, is meant a separation at 
the costo-chondral junction. 

The injury is so closely allied to fracture of the cartilages that the 
reader is referred for other details to Chapter XVIII. of the volume on 
Fractures. 

Dislocation of the Costal Cartilages from the Sternum.. 
(Luxatio Chondro-sternalis.) 

Of this injury there are twelve recorded examples : Ravaton, Man- 
zotti, Monteggia, and Bell, quoted by Malgaigne ; Cooper, 3 Flagg, 4 
Wolfenstein, 5 Gross, 6 Bennett, 7 Mulvany, 8 and Blodgett, two cases. 9 
There are, in addition, one or two cases, elsewhere referred to (see Chap. 
XIII.), in which separation of the first and second pieces of the sternum 
has been accompanied by complete separation of the second costal car- 
tilage from the sternum on one or both sides. 

In three of the cases (Bell, Cooper, and Blodgett's second) the cause 
appears to have been traction exerted through the pectoralis major, in 
swinging dumb-bells, kneading bread, and exercising on parallel bars ; 
and possibly the cause was the same in Blodgett's first case, in which a 
man while carrying a piano made a violent effort to prevent its fall. In 
three others the cause was a fall ; in the remainder it is unrecorded or 
obscure. 

1 De Kimpe: Gaz. des Hopitaux, 1852, p. 18. 

2 Guilt: Loc. cit., vol. 2, p. 250. 

3 Cooper : Loc. cit., p. 451. 

4 Flagg: Northwestern Med. and Surg. Journal, August, 1871, quoted by Ham- 
ilton. 

5 Wolfenstein : Allg. Wiener Med. Ztg., 1873, No. 44, quoted by Poinsot. 

6 G-ross : Surgery, 6th ed., vol. I., p. 1132. 

7 Bennett: Dublin Journal Med. Sc. 1879, I. p. 441. 

8 Mulvany: Lancet, 1882,1. p. 432.' 

9 Blodgett: N. Y. Med. Journ,1883, vol. 38, p. 34. 



DISLOCATION OF ONE CAKTILAGE UPON ANOTHER. 171 

The fourth cartilage was displaced singly forward in three cases, for- 
ward in combination with the fifth and sixth in two, and backward with 
the second and third in one; the third singly, the fifth and sixth together, 
and the fifth, sixth, and seventh together were each displaced forward in 
one case, and the first and second were together displaced forward and 
outward once (Blodgett's first). In two cases it is not stated which 
cartilage was displaced, nor in what direction. 

The only autopsy was in Bennett's case. The patient was a woman 
about fifty-six years old who had been run over by a cart and died a few 
days later of pleurisy and pneumonia. The third cartilage on the left 
side was displaced forward, and there was also fracture of the second, 
third, fourth, and fifth ribs on the same side, and of the second to the 
ninth ribs on the right side. The perichondrium with the attached liga- 
ments was stripped clean off. The dislocation was reduced by direct 
pressure and did not recur ; it must be remembered, however, in con- 
nection with this, that the corresponding rib was broken. 

In the single case of backward dislocation (Mulvany) the patient was 
a boy fifteen years old, who while steering a ship in a heavy storm was 
thrown violently across the deck by a wave and struck upon the back of 
his left shoulder against the deck-house. The second, third, and fourth 
left cartilages were displaced backward behind the sternum, and the 
sternal end of the right clavicle was dislocated forward. Reduction 
could be effected by drawing the shoulders backward, but the displace- 
ment immediately recurred when the traction ceased. The patient was 
kept upon his back for eighteen days, and the deformity was then found 
to have been much diminished. In two months he was again at work. 

Usually there has been sharp local pain at the moment of the accident, 
subsequently excited by movements of the thorax and by local pressure. 
In one case (Mulvany) there was slight recurrent hemoptysis. 

The recognition of the injury appears always to have been easy, by 
attention to the difference in level between the cartilage and the sternum. 
In only one case (Wolfenstein) was it mistaken for a local inflammation. 

Reduction of the forward dislocations was in every case easily effected 
by direct pressure, but the tendency to recurrence w T as marked. 

The best treatment w T ould appear to be the application over the dis- 
placed cartilage and around the chest of a broad strip of adhesive plaster, 
as in fracture of a rib, making special local pressure, if necessary, with a 
compress. Possibly a truss could be used with advantage. 

Dislocation of one Cartilage upon Another. (Luxatio 
Chondro-Chondralis.) 

To our knowledge of this subject nothing has been added since Mal- 
gaigne wrote upon it ; he collected three cases, one of which came under 
his own observation. They are, in brief, as follows : 

Martin. A man seventy years old, while trying to rise from a strained 
semi-recumbent posture, felt a very painful snap in his chest. Notwith- 
standing the swelling of the soft parts, an elevation of the cartilages of 
the last three true ribs (fifth, sixth, and seventh), on the right side, 
which made this side much more prominent than the other, could be dis- 



172 DISLOCATION OF ONE CAETILAGE UPON ANOTHER. 

tinctly seen, and the hand could be readily passed under them. He was 
treated by the application of compresses and a body bandage for a month. 
The elevation persisted, but was smaller than at first. 

Boyer. Of this case Malgaigne says only " Boyer, who saw a similar 
case under analogous circumstances, was also struck by the prominence 
of the upper cartilage, but recognized that it was the lower one that was 
dislocated backward." 

Malgaigne. A man, while pressing a lever forcibly down with his 
left hand, his body being inclined to that side, felt under his left breast 
a snap with a sharp pain which for the moment prevented him from 
straightening himself. Nine years later the deformity attracted the 
attention of Dr. Seger, who brought him to Malgaigne. The cartilages of 
the seventh, eighth, and ninth ribs were depressed below the level of the 
sixth and tenth, which thus formed the borders of a groove at the bottom 
of which the intermediate ones lay. The skin formed a marked fold in 
this groove. The three depressed ribs were approximated to and imbri- 
cated upon one another, their intercostal spaces being almost obliterated 
in front. The dilatation of the chest during inspiration was less on the 
left than on the right side, the patient's gait was a little uneven, and the 
trunk inclined forward on the left. 



CHAP TEE XV. 



DISLOCATIONS OF THE CLAVICLE. 



The percentages of the frequency of dislocations of the clavicle in the 
different tables of statistics that have been published vary greatly from 
one another (see Chapter I.). Thus, of 400 cases of recent traumatic 
dislocations collated by Kronlein 6 were of the sternal end of the 
clavicle and 11 of the acromial end, 1.5 and 2.7 per cent, respectively ; 
of 420 collated by Prahl the corresponding numbers were 10 and 3, or 
2.38 and 0.73 per cent. In Table III., Chapter I., a total of 1432 
dislocations gives 45, or 3.1 per cent., of the sterno-clavicular joint, and 
14, or 0.9 per cent., of the acromio-clavicular, while another of 964 
cases treated in hospital gives 68, or 7 per cent., of the sterno-clavicular 
joint and none of the acromial. Polaillon 1 says that of 967 cases of dis- 
location treated in the Paris hospitals during four years, 1861-64, 87, or 9 
percent., were of the clavicle. During the same period 609 fractures of 
the clavicle were treated. Of the 87, 84 were in men, 3 in women ; 85 
were adults, and 2 were aged. Of 97 reported cases collected by him from 
medical books and journals, 77 were in men, and 17 in women ; in 3 the 
sex was not stated. He gives the following table of 66 cases classified 
according to sex and age : 

Table VIII. — Dislocations of the Clavicle 



Under 10 years 
10 to 15 
15 " 20 
20 " 30 
30 " 40 
40 " 50 
50 " 60 
Above 60 



ICLE 


; Sex and Age. 


lale. 


Female. Tota 


1 


2 3 


2 


2 


2 


4 6 


8 


2 10 


13 


2 15 


15 


15 


6 


2 8 


5 


2 7 



52 14 66 

And the following of 97 classified according to the variety : 



Table IX. 
Acromial end, 

Sternal end, 
Both ends, 



-Dislocations of the Clavicle ; Varieties. 

Male. Female. 

f 38 upward 
50-1 6 downward 

( 6 subcoracoid 

f 19 forward 
4.4 < 16 backward 

( 9 upward 



i Polaillon 
(1875.) 



Diet. Encyclopedique des Sciences Med 



32 


3 3 


5 


1 


4 


2 


14 


5 


13 


3 


7 


2 


2 


1 


3d. 


Article, Clavicule, 



p. 717. 



174 DISLOCATIONS OF STERNAL END OF CLAVICLE. 

Of 50 cases observed by Hamilton, 9 were of the sternal and 41 
of the acromial end. 

The dislocation may be of either end or of both, and occasionally both 
clavicles have been simultaneously dislocated. 



Fig. 




Frontal section through the sterno-clavi- 
cular joint. A, rhomboid or costo-clavicular 
ligament ; B, meniscus ; C, interclavicular 
ligament. (Henle.) 



A. Dislocations of the Sternal End of the Clavicle. 

Anatomy. — The sternal end of the clavicle is so much larger than the 
clavicular notch of the sternum with which it articulates that it projects 

above it and in front and behind. The 
articular surfaces are separated from each 
other by an interposed fibrocartilaginous 
disk, or meniscus, of varying thickness, 
which fills the gaps created by the un- 
symmetrical irregularities of the two 
surfaces and by their inclination to each 
other, and extends below the lower edge 
of the clavicle, separating it also from 
the cartilage of the first rib. This men- 
iscus is most strongly attached above to 
the upper edge of the end of the clavicle, 
and below to the cartilage of the first 
rib. On each side of it is a synovial 
cavity. The ligaments of the joint 
are the interclavicular, costo-clavicular, 
and the anterior and posterior sterno- 
clavicular. The inter-clavicular ligament extends across from the upper 
edge of the end of one clavicle to that of the other above the inter- 
clavicular notch of the sternum, sending bundles of fibres into the 
meniscus and to the top of the sternum. The costo-clavicular ligament 
extends from the sternal end of the first rib upward and outward to the 
under surface of the clavicle as far as to the subclavian vein, partly 
surrounding the inner end of the subclavius muscle but lying mainly 
behind it. It sometimes contains within itself a bursa of considerable 
size. The anterior and posterior sterno-clavicular ligaments cover in 
the joint in front and behind respectively, mainly constituting its cap- 
sule. They are short and quite tense. 

Motion is possible about all the axes, but only to a comparatively 
limited extent, the extreme opposite limits being distant about 60° from 
each other ; that is, the acromial end of the bone can be made to describe 
a circle which is the base of a cone having an angle of 60° at its apex 
in the joint. Movement of the shoulder downward or downward and 
backward is arrested by contact of the clavicle with the first rib, and 
if then continued this point of contact becomes the centre of motion, or 
the fulcrum, and the sternal end of the clavicle is forced upward or 
forward out of its place, and a dislocation is produced. 

Varieties. — The dislocation may be complete or incomplete, upward, 
forward, or backward ; and when complete it is usually also inward, 
toward the median line, and when complete forward or backward, it is 
usually also downward. Possibty a separate class of dislocations, upward 



DISLOCATION OF CLAVICLE FORWARD. 175 

and outward, should be made of such cases as those of Stokes {vide infra) 
in which the cause is the prolonged action of the sterno-cleido-mastoid 
muscle in forced inspiration. 

Dislocation Forward. (Luxatio Clavicul^: Pr^esternalis.) 

This is the most common form, and is usually caused by the shoulder 
being forced backward, or backward and downward. The means by 
which this movement has been produced are various ; in some cases it 
has been a fall upon the point of the shoulder or upon the extended 
hand ; in others, the pressure of some heavy object upon the front of the 
shoulder when the body was supine, as the wheel of a wagon or the foot 
of a horse ; in others, again, by the sudden slipping of a heavy burden 
carried upon the back by straps passing around the shoulders. Richerand 1 
reported a case in which it was caused in a girl twenty years old by the 
forcible approximation of her elbows behind her back, and Boyer another 
in which the shoulders were drawn back to give the patient, a young 
girl, a more erect and graceful carriage, In like manner, it has been 
caused by the voluntary throwing back of the shoulders, as in soldiers at 
drill, and in one case, Bardenheuer, 2 by the involuntary effort made to 
prevent the fall of a burden carried upon the head. 

In all of these the mechanism is the same ; the outer end of the clavicle 
is carried back to the limit of the normal range of motion, and then it 
either finds a new centre of motion at the point at which it comes into 
contact with the first rib, in consequence of which the inner end is carried 
forward if the movement is prolonged, or, as claimed by Morel-Lavallee, 
the limit of the normal range is reached without such contact with the 
rib, the anterior sterno-clavicular ligament is put upon the stretch and 
ruptured, and then dislocation takes place. The latter explanation fails, 
I think, to account for the displacement of the bone, since even after the 
anterior ligament has been torn bv the angular movement backward, 
direct propulsion forward is necessary to overcome the resistance of the 
posterior one, and unless another suitable force is superadded this can be 
effected only by such change of motion as would be produced by the in- 
terposition of the new fulcrum assumed in the first explanation. 

Other cases in which the mode of action is not entirely clear, although 
possibly the same as the above, are Melier's, in which the dislocation 
was caused in a child by grasping its arm to save it from falling from a 
carriage, and Holden's, 3 in which it was caused by violent exercise in a 
gymnasium. 

Holden's case is of interest also for other reasons : the dislocation was 
readily reduced, and the bone remained in place for six months ; then, 
while the patient was putting on his coat the dislocation was reproduced, 
and again, a few days later, while doing the same thing, the sternal end 
of each clavicle was dislocated, " and from that time the phenomenon 
recurred frequently until the inconvenience had become unbearable." 
Even raising the hands to the face would reproduce it. The dislocation 



Bardenheuer, Deutsche Chirurgie, Lief. 63, a, p. 57. 
Kicherand : quoted by Polaillon : Loc. cit., p. 729. 
Holden: N. Y. Medical Journal, 1873, vol. 18, p. 622. 



176 DISLOCATION OF CLAVICLE FORWARD. 

was upward and forward, and " equal to the diameter of the end of the 
bone." 

It was successfully treated by the prolonged wearing of an artificial 
sternum of leather with a prolongation or horn at each upper corner. 
This was moulded to the parts while wet, the horns being pressed down 
over the clavicles, and, when dry, was lined with buckskin and supplied 
with a strap and buckle at the end of each horn and its lower extremity. 
By means of these straps it was made fast to a broad belt about the 
waist. 

In a few cases the dislocation has been caused by the pressure of an 
aneurism at the root of the neck, and in others 1 by prolonged, forced, 
inspiratory efforts. In the latter (two cases) the dislocations appear to 
have been primarily upward, and the displacement forward to have been 
the consequence of the elongation of the ligaments. In one of them 
both clavicles were dislocated. 

Cazin 2 reported a case in which the dislocation was gradually produced 
in a boy eleven years old who was suffering from Pott's disease of the 
dorsal spine with angular deformity and retraction of the corresponding 
side of the chest, and who had the habit of resting on his elbows in bed. 
Cazin thought the displacement was due to the diminution of the size of 
the upper part of the chest, not to the force exerted through the arm. 

In a case reported by Heusinger 3 the sternal end of each clavicle in a 
boy fifteen years old could be readily displaced forward, upward, or back- 
ward simply by the movements of the arms. The condition had never 
been noticed by the boy or his parents, and is spoken of by the reporter 
as congenital. The condition of the parts was characterized by great 
laxity of the ligaments between the sternum and the meniscus, the latter 
remaining closely attached to the clavicle and sharing in its movements. 

Age. — According to Bardenheuer, Fergusson met with a case in which 
the dislocation was produced in a child during delivery. The next 
earliest age at which the injury has been reported is ten months ; it was 
caused by a fall from bed. 4 

Pathology. — The dislocation may be complete or incomplete ; in the 
latter form the posterior portion of the articular surface of the clavicle 
remains in contact with that of the sternum, and the anterior sterno- 
clavicular ligament alone is ruptured. In the former the articular 
surfaces are completely separated, and the posterior edge of that of the 
clavicle rests upon the front of the sternum ; ordinarily it lies nearer the 
median line and at a lower level than that of its normal position, the 
greatest recorded displacements being one mentioned by Bicherand, three 
inches downward, another reported by Jousset 5 in which the end of the 
clavicle lay upon the second rib. This displacement inward or downward 
or in both directions must be secondary and due to the action of the 
weight of the corresponding limb and to the contraction of the muscles 
which draw the shoulder inward, downward, and forward when it is 

1 Stokes: Dublin Med. Journ., 1852, vol. 13, p. 459. 

2 Cazin : Gaz. de Hopitaux, 1874, vol 47, p. 507. 

3 Heusinger: Arch, fur path, anat., 1867, vol. 39, p. 339. 

* T. K. Wright: Boston Medical and Surgical Journal, 1880, vol. 102, p. 333. 
5 Jousset : Gaz. Medicale, 1833, p. 217. 



DISLOCATION OF CLAVICLE FORWARD. 177 

deprived of its normal support, in the same manner and for the same 
reasons as after fracture of the clavicle. (Fractures, p. 337.) The 
opportunities for post-mortem examination have been so few that a posi- 
tive account of the condition of the ligaments cannot be given. That 
the anterior one is ruptured cannot be doubted, and it is probable that 
the posterior one also is torn, although in some cases it may only be torn 
from its attachment and left continuous with the stripped-up periosteum 
of the posterior surface of the clavicle. In one case 1 all the ligaments 
except the anterior sterno-clavicular are described as intact ; the men- 
iscus accompanied the clavicle and was partly torn. In a case reported 
by Cloquet 2 there was found at the autopsy instead of rupture of the 
posterior ligament a fracture that split the end of the clavicle into two 
parts, the posterior one of which remained in place, while the anterior 
one, continuous with the shaft of the bone and capped by the meniscus, 
was dislocated forward. Whether or not the meniscus habitually accom- 
panies the end of the clavicle in its displacement is not known. 

In the cases in which the dislocation has been slowly produced, 
Stokes's arid probably Heusinger's, the ligaments were found greatly 
elongated but not torn. Stokes does not mention the position of the 
meniscus : in Heusinger's case it accompanied the clavicle. 

Occasionally a portion of the edge of the articular surface of the 
sternum or of the clavicle has been broken off. The sternal portion of the 
sterno-cleido-mastoid may be pushed aside or even torn away from the 
sternum, perhaps bringing with it a scale of bone. 

Simultaneous dislocation of the acromial end (vide infra) and fracture 
of the shaft have been observed as complications. 

Symptoms. — The principal physical sign is the projection of the end 
of the clavicle and, if the dislocation is complete, its displacement toward 
the median line or downward. If the dislocation is incomplete the pro- 
jection can be made to disappear by pressing it backward, but it is likely 
to reappear when the pressure is removed. In the complete dislocations 
the extent and direction of the displacement vary with the extent to 
which the ligaments have been torn and with the character of the dislo- 
cating force and the influences to which the limb has been subjected since 
the accident. The weight of the limb, if unsupported, tends to bring 
the shoulder nearer the thorax and thus forces the end of the clavicle 
inward or downward. If the head and neck are maintained erect the 
clavicle is kept at or near its normal level by the clavicular portion of 
the sterno-cleido-mastoid and the cervical fascia, but if, as seems to be 
usually the case, the head is inclined toward the injured side to relieve 
the pain, this support is lost and the bone is left free to descend to a lower 
level. 

The other symptoms are sharp local pain, which is greatly abated in a 
day or two, depression of the shoulder, inclination of the head toward 
the injured side, and inability to raise the arm. 

The local swelling may be so great as to mask the position of the 
bone, and if crepitation should be present the injury may be, as it has 

i Bull, de la Soc. Anato.mique, 1879, p. 809. 

2 Cloquet: Nouveau Journ. de Med. 1820, vol. 7, page 248, quoted by Polaillon. 

12 



178 



DISLOCATION OF CLAVICLE FORWARD, 



been, mistaken for fracture. Another error of diagnosis has been to 
mistake the dislocated end for an exostosis ; and, conversely, hypertrophy 
of the bone has been mistaken for a dislocation. 

The prognosis is unfavorable as regards the complete correction of the 
deformity, but favorable in respect to the restoration of function. In 
almost all the reported cases projection of the end of the bone, to a 
greater or less extent, has persisted, but the patients have been able to 
use the arm freely and with no sense of loss of power, even when the 
dislocation has remained complete. Holden's case, above quoted, is 
exceptional in both respects. The inconvenience of the displacement is 
spoken of as- " unbearable," and the permanent reduction appears to 
have been complete. 

Treatment, — Reduction is effected by drawing the shoulder outward 
and slightly backward and making pressure backward on the dislocated 
end after it has been thus brought opposite the joint. Hamilton failed 
in two cases to effect reduction, but I have met with no other reported 
failures. The reduction is, however, the least part of the treatment ; 
the difficulty is to keep the bone in its place. Many methods, including 
most of those that have been used in fracture of the clavicle, have been 
tried, and often in combination with direct pressure upon the end of the 
bone. Velpeau and Malgaigne recommended that the shoulder should 
be kept drawn forward, a recommendation that seems justified on 

Fig. 38. 







Kecamier's dressing for fractured clavicle. 



anatomical grounds but has not yielded good results in practice ; prob- 
ably the failure is due to the same cause that has rendered the posterior 
position of the shoulder inefficient, the difficulty of maintaining it. 



DISLOCATION OF CLAVICLE BACKWARD. 179 

A simple method that has yielded fairly good results is a figure-of-8 
bandage around the shoulders, the turns crossing over a pad on the back. 
Or the bandage may be attached to the pad as in the dressing recom- 
mended by Recamier for fracture of the clavicle (Fig. 3-3). 

Direct pressure, usually in conjunction with fixation of the shoulder, 
has been applied in a great variety of ways, of which the simplest, which 
may serve also as the type, was that employed by Xelaton. He used an 
ordinary spring-truss, placing one of its pads upon the sternal end of the 
clavicle and the other between the shoulder-blades, and carrying the 
spring under the axilla of the uninjured side. The objection to the use 
of pressure arises from the probability of irritating the skin or even 
causing a slough at the point at which it is applied. Combined with 
rest in bed upon the back and a good position of the shoulder, the main- 
tenance of the pressure for a week has proved sufficient to prevent recur- 
rence although not entirely to overcome the projection. 

Demarquay proposed to mould a leather cape accurately to fit the bust 
of the patient, and to reinforce its pressure by a spring and pad fitted 
over the end of the bone. An objection to the dressing arises from its 
expensiveness. Probably an efficient substitute could be made of plaster- 
of-Paris, and the fixation of the shoulder could be assured by enveloping 
the chest and the upper arm in the plaster and connecting them by 
means of iron braces. Such a dressing could be made to leave the inner 
end of the clavicle open to inspection, and would furnish a support for 
the attachment of a compressing pad, if that should be necessary. 

Le Fort 1 obtained excellent results in two cases by moulding a piece of 
gutta-percha over the lower part of the neck and upper part of the chest 
so as to cover both sterno-clavicular joints and about two-thirds of the 
dislocated clavicle, and keeping it in place by straps or a truss. 

Possibly the dressing employed by Holden (ut supra) would be entirely 
efficient to keep the bone in place. The brief account of his case leaves 
it somewhat uncertain whether or not the reduction was complete. 

In a case in which the total correction of the displacement should be 
important, the patient should be kept in bed upon the back, in order to 
diminish the tendency to reproduction of the deformity created by the 
weight of the shoulder when the body is erect, and frequent inspection 
should be made to determine the efficiency of the measures. Should all 
other means fail, digital pressure should be maintained for a week or ten 
days. The dressings should be worn for at least a month. 

Dislocation -Backward. (Luxatio Clayiculje Retro- 
sterxalis.) 

This dislocation, the second in order of frequency of those of the 
sternal end, may be produced directly, by a force acting from before 
backward upon the end of the bone, or indirectly, by a force that presses 
the shoulder forward and inward. The latter is the more frequent. In 
the few recorded cases of dislocation by direct violence the cause has 
been such as the fall of the patient forward, striking upon the clavicle, 

1 LeFort: Gaz. des Hopitaux, 1885, p. 369. 



180 DISLOCATION OF CLAVICLE BACKWARD. 

or the fall upon him of a stone, or the passage across his chest of the 
wheel of a wagon, and in one case the point of a pickaxe was driven 
through the skin over the cartilage of the second rib by the caving-in of 
a bank of earth, and then, passing upward, forced the clavicle out of 
place. In the dislocations by indirect violence the patient has commonly 
been caught between two bodies, as the pole of a wagon and a wall, or 
the side of a railway car and a wall, or between two boats, in such a way 
that the shoulder has been pressed forward and inward. 

A case mentioned by Sir Astley Cooper 1 is frequently quoted as one 
in which the dislocation was caused by progressive distortion (scoliosis) 
of the spine. It appears, however, that the dislocation was due to an 
accident, and that the subsequent change in the shape of the spine only 
increased the unreduced displacement until it seriously interfered with 
deglutition. The end of the clavicle was then removed by operation. 

The dislocation may be complete or incomplete. 

Pathology. — Until quite recently the only recorded case in which a 
direct examination of the parts had been made was the one of compound 
dislocation mentioned above in which the injury was caused by the point 
of a pickaxe. It was reported by Tyrrell.' 2 The pectoralis major was 
freely torn from its attachment to the clavicle, bat in all probability this 
was mainly, if not entirely, the result of a direct action upon it of the 
point of the pickaxe, and is not a common feature of the dislocation. 
The meniscus remained attached to the sternum, and the end of the 
clavicle could be easily felt by the finger in the wound. 

A second case was reported by Bennett 3 in 1881 ; the patient was 
caught between a wall and a railway car and rolled along for some dis- 
tance. The sternal end of the right clavicle, accompanied by the meniscus, 
was dislocated backward, and the cartilages of the first, second, third, 
and fourth ribs of the same side w T ere broken. 

The end of the bone is displaced inward or inward and downward, and 
it is generally stated that it lies between the trachea and the sterno- 
hyoid and sterno-thyroid muscles, but, in the absence of direct proof of 
this, I am disposed to believe that it may rather lie between the latter 
muscle and the sternum, and below the former, for, it will be remembered, 
the sterno-hyoid arises in part from the posterior ligament of the joint 
and frequently from the clavicle itself, and the sterno-thyroid lies behind 
the other and has its origin as low even as the cartilage of the second 
rib. Possibly the difference noted in the direction of the displacement, 
inward in some, inward and downward in others, may depend upon 
varying relations between the bone and these muscles. 

Whatever the relations between these parts may be, the end of the 
bone frequently presses upon the trachea and thereby causes more or less 
dyspnoea, or upon the oesophagus and causes dysphagia. Of sixteen 
cases analyzed by Polaillon dyspnoea was present in six, and dysphagia 
in three. The venous congestion of the face and neck coexisting with 
the dyspnoea has been sometimes attributed to pressure upon the brachio- 

1 Cooper: Disloc. and Fractures, Am. ed., 1844, p. 309 

2 Tyrrell : St. Thomas Hosp. Keports, 1836, vol. i. p. 261. 

3 Bennett: Dublin Journ. Med. Sci., 1881, vol. 71, p. 444. 






DISLOCATION OF CLAVICLE BACKWARD. 181 

cephalic vein, but although the region into which the end of the bone is 
displaced is occupied by most important vessels and nerves, the recorded 
histories do not show that they have ever been seriously pressed upon. 
Some authors, quoting other accounts of Cooper's case, say that pulsation 
was arrested in the radial artery on the corresponding side ; if this was 
so, it was probably due to compression of the subclavian artery between 
the clavicle and the first rib. 

Beside the complication of fracture of the cartilages of the first four 
ribs in Bennett's case mentioned above, fracture of the first rib has been 
noted in a case reported by Dr. N. C. Morse . -1 the patient was a girl 
eight years old who had been run over by a wagon and had received a 
dislocation backward of the sternal end of the left clavicle, with fracture 
of the first rib, and a dislocation " outward " (forward ?) of the sternal 
end of the right clavicle. Apparently the wheel had crossed the left 
clavicle and chest. There was great dyspnoea and marked venous con- 
gestion of the face and neck which disappeared on reduction of the 
dislocation. The child recovered. 

Symptoms. — The absence of the end of the clavicle from its articula- 
tion, and its position behind the sternum are recognizable by inspection 
and palpation, the course of the bone can be seen and felt to pass inward 
behind its normal position, and the cavity and border of the articular 
surface of the sternum can be traced with the finger. Morel-Lavallee 
called attention to the marked projection forward of the acromial end of 
the clavicle and claimed that this was a characteristic sign. Its value, 
which at the best is so much less than that of the recognition of the 
position of the sternal end, is still further diminished by the normal 
differences in the prominence of the acromial end. 

The shoulder hangs a little forward and nearer the chest ; sharp pain, 
increased by movements of the arm or head, is felt at the seat of injury, 
but usually is prompt to disappear. These voluntary movements are 
restricted or abolished by the pain. 

Disturbance of respiration by compression of the trachea has been 
noted in only about one- third of the cases, and may be slight or so severe 
as to threaten suffocation. Ordinarily it lasts for only a short time, even 
if the dislocation remains unreduced. 

Difficulty in swallowing has been less frequently noted than dyspnoea 
(three times in sixteen cases). 

The prognosis is favorable as regards the reestablishment of function 
even if the dislocation is not reduced, and reduction is, as a rule, easy, 
and retention more complete than after dislocation forward. 

Treatment. — Reduction can commonly be effected by drawing the 
shoulder outward and backward, and this seldom requires more force than 
the surgeon himself can exert without assistance. In one case Lenoir 
was obliged to provide counter-extension by a bandage carried around 
the chest and made fast to the wall, and extension by another bandage 
passed around the upper part of the arm and drawn upon by two assis- 
tants while a third held the elbow near the side. In another of his cases 
one assistant placed his knee against the patient's back and drew his 

1 Morse: Cincinnati Med. News, 1877, vol. 6, p. 819. 



182 DISLOCATION OF CLAVICLE UPWARD. 

shoulder backward while a second assistant held up the chin, and Lenoir 
passed his fingers down behind the end of the clavicle and pressed it 
forward. Reduction took place promptly and with a distinct snap. 

Recurrence of the displacement should be opposed by dressings that 
hold the shoulder back and down. Arnaud aided this by keeping the 
forearm behind the back, an efficient measure but one that might prove 
very irksome. The necessity exists as in dislocation forward to examine 
the joint frequently with the object of promptly detecting and correcting 
any faulty position, and to wear the dressings for several weeks. 

Dislocation Upward. (Luxatio Clavicul^: Suprasternalis.) 

The first recorded case of this form of dislocation was published by 
Duverney 1 in 1751, the next was observed by Sedillot 2 in 1835, and 
Malgaigne in 1855 could collect only five cases. The number is now 
increased to about twenty, 3 with two autopsies, Duverney's and R. W. 
Smith's. 4 Morel-Lavallee thought the displacement was always secondary 
to a dislocation backward, an opinion which has not been accepted by 
others. For reasons given above I am inclined to believe that the essen- 
tial difference between the two forms is to be found in the relations of the 
displaced end of the bone to the sterno-hyoid muscle, that in the back- 
ward dislocation it lies below or possibly behind it, and in the upward 
dislocation in front of it. In like manner it differs from the forward 
dislocation in that the bone lies behind the sternal portion of the sterno- 
cleido-mastoid muscle instead of in front of and below it. 

The cause in the sudden, traumatic cases, is the forcible depression of 
the shoulder and the acromial end of the clavicle, by w T hich the upper 
portion of the capsule is torn and the end of the bone lifted out of the 
joint; then, the force continuing to act and pressing the shoulder inward 
toward the chest, the bone is forced inward to or beyond the median line 
and sometimes upward so far even as to rest upon the anterior surface of 
the larynx. A unique mode of production was reported by Dr. A. N. 
Blodgett. 5 The patient was carrying one end of a piano when the two 
men who were carrying the other end allowed it to fall. The patient 
felt sharp pain at the root of the neck and front of the chest, and it was 
found that the sternal end of the right clavicle had been dislocated 
upward and inward and that the first and second costal cartilages of the 
same side had been dislocated from the sternum forward and outward. 

In Duverney's case all the ligaments were torn and the periosteum 
was stripped from the end of the clavicle ; doubtless, therefore, the 
meniscus remained attached to the sternum. In R. W. Smith's case 
(Fig. 34), the end of the left clavicle rested on the upper border of the 
sternum in contact with the right sterno-cleido-mastoid, having passed 
behind the sternal portion of the left sterno-cleido-mastoid and in front 

1 Duverney : Traite des Maladies des Os, vol. i. p. 201. 

2 Sedillot : Contributions a la Chirurgie, 1868, vol. i. p. 261. 

3 For the bibliography see Malgaigne, Hamilton, and Polaillon, and cases here 
mentioned passim. 

4 E. W. Smith : Dublin Journ. Med. Sci., 1872, ii. p. 450. 

5 Blodgett : New York Medical Journal, 1883, vol. 38, p. 44. 






DISLOCATION OF CLAVICLE UPWARD 



183 



of the sterno-hyoids. The clavicular portion of the left sterno-cleido- 
mastoid was relaxed, its sternal portion tense. The anterior and pos- 
terior sterno-clavicular ligaments and the costo-clavicular were torn ; the 
meniscus accompanied the clavicle. The subclavius muscle was relaxed 
but not torn. There was dyspnoea and dysphagia ; death was the result 
of associated injuries. 

Fig. 34. 




Dislocation upward of the sternal end of the clavicle. (E. W. Smith.) 

In a case reported by Stokes 1 , and mentioned above, the dislocation is 
described as forward and upward, and the joints as being so loose that 
the sternal end of each clavicle could be easily moved in any direction ; 
this condition had been produced by the ' k powerful action of the sterno- 
cleido-mastoid muscles" in forced inspiratory efforts provoked by great 
dyspnoea due to ascites. At the autopsy the ligaments were found to be 
greatly stretched, the sterno-clavicular being half as long again as natural 
and the rhomboids (costo-clavicular) also elongated. The relations of the 
end of the clavicle to the sternal portion of the sterno-cleido-mastoid are 
not stated, and it remains uncertain, therefore, whether the case properly 
belongs in the class of dislocations upward. 

Symptoms. — If the dislocation is incomplete the only symptoms are 
the projection of the end of the clavicle above its normal position, and 
the local pain increased by movements of the head and arms. 

The symptoms of the complete form are the recognizable displacement 
of the end of the bone inward and upward to a variable distance, its 
position behind the sternal portion of the sterno-cleido-mastoid of the 
same side, the tension of this portion of the muscle, the depression of the 
shoulder, and its approximation to the chest; local pain, sometimes 
dyspnoea and dysphagia, inhibition of voluntary movements of the shoulder 
and head because of pain, and sometimes the impossibility of passively 
raising the shoulder. The supra- and infraclavicular fossae are altered, 

1 Stokes : Dublin Med. Journal, 1852, vol. 13, p. 459. 



184 



DISLOCATIONS OF ACROMIAL END OF CLAVICLE. 



and the emptiness of the clavicular notch of the sternum may perhaps be 
recognized by palpation. 

Treatment. — Reduction is effected by drawing the shoulder outward 
and making direct pressure downward and outward upon the sternal end 
of the clavicle, but here again the chief difficulty is to prevent recurrence. 
Fixation of the shoulder by various dressings, and the recumbent position 
to avoid the depression of the shoulder by the action of gravity, have 
been employed with a fair measure of success, the resulting deformity 
being slight, and the re establishment of the usefulness of the arm com- 
plete. Bardenheuer 1 found by experiments upon the cadaver that the 
dislocated bone could be kept in place so perfectly by Malgaigne's hooks 
that the most extensive movements communicated to the arm and shoulder 
would not displace it. One of the hooks was engaged in the clavicle, 
the other in the sternum. The plan employed by Holden in his case of 
dislocation forward (p. 176), might be equally efficient in this form. 

B. Dislocations of the Acromial End of the Clavicle. 

Anatomy. — The outer portion of the clavicle is attached to the scapula 
at two points, namely: at its extreme end to the inner margin of the 
acromion by the acromio-clavicular joint, and further inward to the cora- 

Fro. 35. 
Trapezoid. 




Ligaments uniting the clavicle to the scapula. (Henlk ) 

coid process by the coraco-clavicular ligaments. The articular surfaces 
forming the acromio-clavicular joint are flat and oval in shape, the long 
axis being antero-posterior, and the upper edge of the end of the clavicle 
rises to a variable distance above the upper surface of the acromion. 
The articular surfaces are separated in part, sometimes completely, by an 
interposed meniscus of fibrous tissue, wedge-shaped, with its base directed 
upward and attached to the broad, strong superior ligament ; the inferior 
ligament, usually much thinner than the superior, closes the joint below. 
The coraco-clavicular ligament is composed of two portions, the postero- 
internal, or conoid, and the antero-external, or trapezoid. The conoid 
ligament, broad above and narrow below, arises from the inner part of 



1 Lnc. cit. 



63. 



SUPRA-ACROMIAL DISLOCATION OF CLAVICLE. 185 

the upper surface of the coracoid process near its root, and passes upward 
and backward to be attached to the broad conoid tubercle on the under 
surface of the clavicle ; the trapezoid ligament arises from the upper 
surface of the coracoid process in front of the conoid and passes upward, 
backward, and outward to be attached to the trapezoid line which extends 
outward from the conoid tubercle along the under surface of the clavicle. 
Between the two ligaments there is frequently a synovial bursa. The 
conoid ligament especially opposes the displacement backward of the 
clavicle on the acromion ; the trapezoid opposes its displacement upward 
and outward. A thin, flat band of fibres runs from the back of the 
coracoid process upward and inward to the clavicle, and is sometimes 
described as the anterior coraco-clavicular ligament, the conoid and 
trapezoid being then distinguished as the posterior coraco-clavicular 
ligament. 

Complete dislocation involves not only rupture of the ligaments of the 
joint proper, but also of the conoid and trapezoid ligaments to a greater 
or less extent. The joint allows motion in all directions, the extreme 
ranges being, according to Albert, 20° to 30° in the horizontal plane, 
and 60° to 70° in the vertical plane; and its dislocation appears to be 
commonly effected, not by extending the movement of the joint beyond 
its normal limit, but by direct displacement of one bone upon the other. 

The clavicle may be displaced upward, supra-acromial dislocation, or 
downward and backward, sub-acromial dislocation, or downward and 
forward under the coracoid process, subcoracoid dislocation. The first is 
by far the most common ; the last has been observed by only two 
surgeons, one of whom reported five cases. 

Some authors, following the system of nomenclature used in the dis- 
locations of other joints, term them dislocations of the scapula, but the 
innovation has not made its way. 

Supra-acromial Dislocation. (Luxatio Clavicul,e Supra- 

acromialis.) 

The dislocation may be complete or incomplete ; in the latter the 
clavicle is displaced upward to a distance equal or nearly equal to the 
vertical diameter of its articular surface ; in the former the separation of 
the articular surfaces is complete, and there is an additional displacement 
outward over the acromion, or outward and backward, or to a greater 
distance upward. 

The cause is usually a blow received upon the point of the shoulder 
and directed downward with an inclination inward, forward, or back- 
ward. The vigorous contraction of the trapezius by which the clavicle 
is prevented from accompanying the acromion in its descent seems to be 
an important, perhaps an essential, factor in the production of the lesion, 
the alternative factor that has been suggested, arrest of the descent of 
the clavicle by contact with the first rib, seems more likely to produce 
dislocation of the sternal end of the bone. Malgaiorie found in one 
case marked tenderness of the trapezius and sterno-cleido-mastoid 
muscles, and cites the fact as proof of the correctness of this theory in 
some cases. The absence of such tenderness in other cases should not, 



186 SUPRA-ACROMIAL DISLOCATION OF CLAVICLE. 

I think, be deemed opposing evidence, for an efficient contraction not 
followed by injury of the muscle is easily conceivable. A case reported 
by Cloquet 1 and sometimes quoted as an example of dislocation by direct 
violence, seems clearly to indicate the important part played by muscular 
action : A man who was carrying a beam upon his shoulder made a 
violent effort to keep it from falling, and found he had thereby produced 
a dislocation. Polaillon 2 mentions a case communicated to him by 
Dolbeau in which the dislocation was caused in a woman by an attempt 
to strike a child. In such a case the momentum of the arm presumably 
takes the place of the more common external violence received upon the 
shoulder. 

A unique case in which the dislocation was caused by a blow received 
upon the clavicle from below upw T ard is reported by Hamilton f a bolt 
three-quarters of an inch in diameter was driven through the skin on the 
anterior margin of the left axilla, breaking the first rib, severing the 
coraco-clavicular ligaments, and forcing the clavicle upward from its place. 

Malgaigne reports a case in which the injury was apparently caused 
by a fall upon the elbow. 

Pathology. — Our knowledge of the character and extent of the lacer- 
ation of the ligaments is derived almost exclusively from clinical obser- 
vation and experiments upon the cadaver, for there is only one reported 
autopsy and one museum specimen. The autopsy, reported by 
Malgaigne, 4 was in a case of incomplete dislocation and showed that the 
articular facet of the clavicle had not entirely left that of the acromion ; 
the superior acromioclavicular ligament was only stretched or perhaps 
slightly torn away from the acromion, and the inferior one was in great 
part ruptured ; on the other hand, the strong coraco-clavicular ligaments 
were torn entirely across. There were other and more serious associated 
lesions, for example, a comminuted fracture of the body of the scapula 
on the same side. 

The museum specimen is one preserved in St. Thomas Hospital and 
mentioned by Sir Astley Cooper. 5 The patient was a man sixty years 
old who died of pulmonary disease seven w r eeks after the receipt of the 
injury. The account from which I quote states only that " the clavicle 
was found dislocated at its scapular extremity, and projected considerably 
over the spine of that bone. The acromion process, just where the 
clavicle is united with it, was broken off." Malgaigne, quoting apparently 
from some other account, says that Cooper supposed that all the acromial 
and coracoid ligaments must have been torn. He adds that this is what 
experiments upon the cadaver indicate, but that it is melancholy to limit 
one's self to conjectures when the specimen itself can be examined. Cooper 
(loc. cit., p. 312) gives also a drawing of a specimen of an old dislocation 
in which the conoid ligament had become ossified. 

Experiments upon the cadaver have yielded results that are not entirely 
in accord with one another. Malgaigne found that even in incomplete 

1 Cloquet : Journal Hebdomadaire, 1830, vol. 7, p. 400, quoted b.y Malgaigne. 

2 Polaillon : Diet. Encyclopedique des Sciences Medicales, art. Clavicule, p. 719. 

3 Hamilton : Fractures and Dislocations, 1880, p. 626. 

4 Loc. cit., p. 432. 

5 Cooper : Dislocations and Fractures, Am. ed., p. 313. 



SUPRA- ACROMIAL DISLOCATION OF CLAVICLE. 187 

dislocation the capsular ligaments were completely, and the coraco-clavi- 
cular partly, ruptured. Bouisson and Ader found that incomplete dislo- 
cation could be easily produced after division of the acromial ligaments 
and without injury to the coracoidal, and even to such a degree that the 
articular surfaces were completely separated vertically from each other. 
Ader further showed that after division of the coracoidal ligaments a 
complete dislocation could be readily produced and the end of the clavicle 
removed to a distance of two centimetres from the acromion. 

Instead of rupture of the upper acromial ligament avulsion of the 
edge of bone on either side to which it is attached has been observed 
clinically. 

Among the recorded complications are simultaneous dislocation of the 
sternal end of the same or of the other clavicle, fracture of the clavicle, 
of a rib, of the acromion process, of the coracoid process, of the body 
of the scapula, and subcoracoid dislocation of the shoulder of the same 
side. 

Symptoms. — In incomplete dislocation the deformity consists in the 
elevation of the end of the clavicle to a variable distance, not greater, 
however, than the thickness of the bone, above the level of the acromion, 
and this elevation can be readily recognized by palpation, and can gen- 
erally be reduced by moderate pressure. 

In complete dislocation the elevation is greater, more than an inch in 
some cases, or is combined with displacement outward, backward, or 
forward. The displacement outward is, of course, due to the approxi- 
mation of the acromion to the chest, and it is greater when the displace- 
ment upward is also greater. The explanation of this latter fact is to be 
found in the presumably more extensive laceration of the ligaments 
uniting the two bones. The greatest recorded overriding is one inch 
(Malgaigne). It has been observed also in some cases that the scapula 
has undergone a movement of rotation by which its inferior angle is 
carried backward toward the spine, and the anterior, upper angle is 
lowered, a movement that is attributed to the action of the weight of the 
arm ; it has been observed only when the displacement inward of the 
scapula toward the chest has not been very marked. 

The clavicle may occupy a position that is symmetrical with that of 
the opposite one, or may be inclined either forward or backward, and is 
then more or less prominent, respectively, under the skin. In a case 
observed by Malgaigne it had undergone rotation about its long axis by 
which its posterior border was raised and its anterior border depressed. 
Its outer end can often be moved quite freely forward and backward 
along the scapula, but it is sometimes fixed by the rigidity of the tra- 
pezius, and then the outer portion of this muscle shows prominently 
under the skin. 

There is local pain, more or less severe, persisting for a variable length 
of time, and increased by pressure or by voluntary movements of the 
shoulder or arm. The attitude resembles that of fracture of the clavicle, 
the head being inclined toward the injured side, and the arm supported 
by the other hand. In the incomplete cases this is sometimes less 
marked, or even absent. The interference with voluntary movements of 
the limb varies greatly, and corresponds measurably with the pain and 



188 



SUPKA-ACKOMIAL DISLOCATION OF CLAVICLE. 




Complete supra-acromial dislocation 
of the clavicle. 



the extent of the displacement ; some patients are completely disabled, 
others can use the limb quite freely. 

The diagnosis is to be made by recognition of the changed relations 
of the bones, which is easy in the cases of complete dislocation, and 

seldom difficult in the incomplete. In the 
latter case the local pain and the possibility 
of reducing the bony prominence by pressure, 
together with its immediate reappearance on 
the removal of the pressure, will give the 
clew. The question will then lie between 
dislocation and fracture of the clavicle near 
its end, and this may be answ r ered by the aid 
of comparative measurements of the two 
clavicles and consideration of the presence 
or absence of signs peculiar to fracture. The 
error of mistaking the injury for a dislocation 
of the shoulder appears to have been quite 
frequently made, although it is difficult to 
understand how it could happen unless the 
soft parts were so swollen that the head of 
the humerus and the outer and anterior borders of the acromion could 
not be felt. The difference in the attitude of the arm is in itself almost 
sufficient for the differential diagnosis, for abduction of the elbow, which 
is- the rule in dislocation of the shoulder, has been observed in only one 
reported case (Hamilton) of dislocation of the clavicle. 

A contusion or sprain of a joint in which the end of the clavicle stood 
abnormally high might easily be mistaken for a recent dislocation, since 
it would present all the signs of one, but the error would be of slight 
importance and would cause no harm to the patient beyond perhaps a 
needlessly prolonged confinement of the limb. 

The prognosis in the incomplete form is good, for although the dis- 
placement has commonly persisted in some measure, the resulting de- 
formity is slight. In the complete form, with marked displacement, 
there is, in addition to the common imperfect maintenance of the reduc- 
tion an occasional inability even to make reduction. In such cases the 
functions of the limb may or may not be seriously interfered with by the 
persistence of the displacement. In the unique case quoted above from 
Hamilton, of dislocation by direct violence acting upon the clavicle from 
below upward, the bone remained displaced two inches upward, yet the 
patient could use the arm as freely and strongly as the other ; and in one 
of Malgaigne's cases the patient, who would not accept any treatment, 
used his arm quite freely after the sixth day. On the other hand, in 
one of Bardenheuer's cases, in which the displacement persisted, the 
diminution of function was considerable, and the power of abduction of 
the arm was almost entirely lost. 

Treatment. — In most cases the reduction of even the complete disloca- 
tions can be readily effected by drawing the shoulder either directly 
upward, or upward and outward, or backward, and at the same time 
pressing the clavicle directly tow T ard its place. The only opposition that 
ordinarily needs to be overcome is the weight of the arm, which draws 



SUPRA-ACROMIAL DISLOCATION OF CLAVICLE. 189 

the shoulder downward and inward away from the clavicle ; with this is 
sometimes associated reflex contraction of the trapezius which draws the 
clavicle upward, and in a few cases the end of the clavicle has passed 
through the trapezius in such a way that the interposed fibres of the 
muscle have constituted a serious obstacle to reduction. To overcome 
this latter obstacle Moutet 1 subcutaneouslv divided the clavicular portion 
of the trapezius close to its insertion and was then able easily to restore 
the bone to its place and keep it there by a bandage. 

In making reduction the arm should be kept near the side and pressed 
directly upward ; if it is abducted the clavicular portion of the deltoid is 
made tense, and thus may oppose the outward movement of the scapula : 
and, in like manner, traction made upon the abducted arm is inappropriate, 
although sometimes successful, because the production of the desired 
effect is opposed by the deltoid and pectoralis major. If the shoulder 
needs to be drawn directly outward, this should be done by the hand 
introduced into the axilla, or by grasping the upper part of the arm with 
both hands, the fingers resting in the axilla, and the thumbs against the 
projecting articular surface of the clavicle, and thus drawing the shoulder 
outward while pressing the clavicle inward. Malgaigne narrates a 
number of cases in which varying positions of the arm modified the ease 
with which reduction could be obtained, but the results were contradic- 
tory, and do not indicate any principle of general application. 

In short, reduction is to be effected by forcing the acromion upward, 
and outward, forward, or backward, as may be indicated by the direction 
of the displacement, by pressure exerted upon it through the humerus, 
by pressing the end of the clavicle in the opposite direction. If the 
clavicle is held high up by the contracted trapezius, either it must be 
lowered by inclining the head toward that side, or the acromion must be 
raised to its level. If the fibres of the trapezius are interposed between 
the bones, and cannot otherwise be got out of the way, they must be 
divided subcutaneously close to their insertion upon the clavicle. 

In incomplete dislocation simple pressure downward upon the end of 
the clavicle will return it to its place. 

The maintenance of the reduction is more difficult. The weight of 
the arm and the contraction of the trapezius constantly tend to reproduce 
the deformity, to carry the shoulder downward, and the clavicle upward. 
A great variety of methods of treatment have been employed, including 
most of the dressings used in the treatment of fracture of the clavicle. 
Most of the special ones seek to raise the acromion by pressure applied 
to the elbow while the forearm is flexed, and to hold down the clavicle 
by pressure applied to its upper surface. Simple bandages passing under 
the elbow and over the shoulder, immovable dressings made with dextrine 
or plaster of Paris, pads, straps, and buckles in various combinations, 
India-rubber bands, and even the common Petit tourniquet, all have been 
tried, and have given good results, and all have met with more or less of 
failure. 

A simple dressing, which can be readily applied, does not slip or 
require renewal, and has given me satisfactory results in these cases, is 

1 Moutet: Montpellier Medical, 1861, vol. 6, p. 219, quoted by Polaillon. 



190 SUPRA- ACROMIAL DISLOCATION OF CLAVICLE. 

the following : A strip of stout adhesive plaster, preferably " moleskin 
plaster," about four feet long, and two or three inches wide, is placed 
with its centre under the elbow, the forearm being flexed at or within a 
right angle, and its two ends are carried upward, one behind, the other 
in front, of the arm, and crossed over the shoulder at a point corre- 
sponding to the end of the clavicle, and then fastened to the front and 
back of the chest respectively. While applying it, the surgeon must 
press the elbow firmly upward, and the clavicle downward. The eye or 
finger can readily detect through the plaster any recurrence of the dis- 
placement. The dressing should be worn for three or four weeks. 

This dressing has, as has been said, given me good results in all the 
cases, three in number, in which I have used it. I do not say perfect 
results, for in two of the three I thought there was still left a slight pro- 
jection. The patients were laboring men, and the other clavicle was also 
prominent; possibly the projection was no greater than before the acci- 
dent. However that may have been, the result would, I think, have 
been satisfactory, even if the patients had been ladies accustomed to 
expose their shoulders. 

It may well be thought that a more extended trial will yield some failures, 
but, nevertheless, the dressing meets the indications more perfectly and 
with less inconvenience to the patient and surgeon than any other I 
know of. 

The India-rubber bandage employed in a similar manner, as first pro- 
posed by Delens, has often given good results, but has sometimes caused 
sloughing of the skin. Dr. W. T. Bull reported to the New York Sur- 
gical Society in 1886 that he had employed it in four cases, getting 
sloughs in the last two, and that he had then abandoned it. It seems to 
me that elasticity is not only not required in the dressing, but is actually 
objectionable ; it allows the bone to be displaced whenever the displacing 
force becomes greater than the strain exerted by the bandage, and at the 
same time it is constantly pressing upon the skin, even when pressure is 
not required, and is thus more likely to cause a slough than adhesive 
plaster, which, being inextensible, opposes displacement more effectively, 
and exerts its pressure upon the skin only at the time when, and to the 
degree that, displacement threatens. 

The tourniquet, which appears to have had a larger measure of success 
than any other method that seeks to meet the indication in this way, is 
used as follows : The skin near the outer end of the clavicle and under 
the elbow is protected by pads of cotton or wool, over each of which is 
placed a plate of card-board or metal to equalize the pressure ; then the 
pad of the tourniquet is placed upon the upper one, and its strap carried 
around under the elbow and made fast to the buckle, and finally, the 
screw of the tourniquet is turned until the desired pressure is obtained. 
A body-bandage immobilizes the arm and supports the forearm, and pro- 
tects the strap from being displaced. By carefully graduating the pressure 
to be used, and shifting it from time to time if necessary, the formation 
of sloughs may be avoided. 

Wiring of the clavicle to the acromion has been practised a few times 
in recent and in old dislocations, but is not generally approved. 



SUBACKOMIAL DISLOCATION. 191 

W. Baum 1 reports good results in three cases of difficult retention 
obtained by suturing together through the skin the ends of the acromio- 
clavicular ligaments, as in Volkmann's method of treatment of fracture 
of the patella by sutures passed through the tendons. A silk ligature 
was passed through the skin and each stump of the ligament and tied in 
a loop, and then the two loops were drawn together over a pad of gauze 
by another thread. The shoulder was enveloped in a simple antiseptic 
dressing, and the arm fixed by a splint. In all three cases the recovery 
was complete in three weeks. 

Subacromial Dislocation. (Luxatio CLAvicuLiE 
Sub acromi alls.) 

This dislocation, of which Petit was the first to make mention, is so 
rare that Polaillon in 1875 could collect only six recorded cases ; the 
list has now been increased to eleven, or, adding Newman's, to twelve. 
The first four, quoted by Malgaigne, 2 are those of Melle, 1765, Fleury, 
1816, Tournel, 1837, and Baraduc, 1842. The others are two observed 
and reported by Morel-Lava llee, 3 one by Dr. W. B. Chase, 4 one by Dr. 
J. X. Allen, 5 and one by Dr. Eaton. 6 Koenig 7 refers to one that was 
observed in Bruns's clinic, and Bardenheuer 8 makes several quotations 
from the report of a case by Uhde but does not give the reference. He 
speaks also of a case reported by Gosselin in 1881, but I have been able 
to find only a clinical lecture by Gosselin on a case of supra-acromial 
dislocation. To these may be added Newman's case of simultaneous dis- 
location of both ends of the clavicle (vide infra), in which the outer end 
was displaced under the acromion. 

The cause in these cases was direct violence exerted upon the upper 
surface of the outer end of the clavicle (Melle, Tournel, Chase), a fall 
upon the shoulder in three (Fleury, Morel- Lavallee's two), and muscular 
effort in one (Allen). In Baraduc's case the patient, a washerwoman, 
felt while at work a sharp pain in her right elbow ; the next morning 
the pain was in the right shoulder, and the bone was said to be movable 
and prominent ; two and a half months later when she entered the hos- 
pital the arm was without strength, the hand could not be raised to the head, 
and the trapezius, rhomboid, and serratus magnus were atrophied. The 
vertebral border of the scapula was very prominent, its inferior angle was 
carried backward and inward, and the anterior angle downward and for- 
ward. The end of the clavicle was displaced backward under the 
acromion. 

Allen's patient, a stout muscular girl sixteen or seventeen years old, 

1 Fortschritte der Medizin, 1886, vol. iv., p. 189. 

a Malgaigne: Loc. cit. p. 448 and 452. Malgaigne thinks Baraduc's case was 
probably pathological, not traumatic. The reference he gives for Tournel is incor- 
rect ; it should be 1837, not 1847. 

3 Morel-Lavallee: Bull, de la Soc. de Chir., 186.3, vol. 4, p. 51 and 240. 

* Chase : Trans. Med. Soc. State of New York, 1879, p. 170. 

5 Allen : New York Med. Kecord, 1881, vol. 19, p. 206. 

6 Eaton: New York Med. Record, 1881, vol. 20, p. 734. 

7 Koenig: Speciel. Chirurgie, 3d ed., vol. 3, p. 16. 

8 Bardenheuer : Deutsche Chir., Lief. 63, a, p. 89. 



192 SUBACROMIAL DISLOCATION. 

was chopping wood, and at the moment she had the axe raised and was 
about to deliver the blow she felt a sharp pain in the shoulder, and the 
arm fell powerless by her side. When seen six weeks later there was a 
marked depression on the top of the shoulder, much discoloration in the 
axilla, and the inferior angle of the scapula was thrown prominently out- 
ward. There was complete loss of voluntary motion of the arm and 
hand, and numbness of the entire limb. Reduction was easily effected 
by drawing the shoulder outward and backward. 

Chase's case may be taken as a type of direct violence. A boy eight 
years old fell head foremost from a height of twelve or fifteen feet and 
struck with the top of his shoulder against the rung of a ladder. An 
ecchymosis over the outer end of the clavicle showed where the blow had 
been received. The acromial end of the clavicle was dislocated down- 
ward and somewhat backward, the shoulder was flattened in front, and 
the acromion very prominent. Reduction, under anaesthesia, was easily 
effected by drawing the shoulder outward and backward and pressing the 
clavicle in the opposite direction. There was no tendency to recurrence, 
and recovery was complete in five weeks. 

Of the other two cases of direct violence, in one, Tournel's, the injury 
was caused by a horse stepping upon the front of the patient's shoulder 
as he lay on the ground ; in the other, Melle's, the patient, w T ho was a 
Russian soldier, attributed the injury to an effort he made when six years 
old to lift, with the aid of another child, a keg of water by means of a 
stick resting on his shoulder. He had also a dislocation of the corre- 
sponding humerus, which apparently had been received at the same time. 

Morel-Lavallee explains the escape of the coracoid process from frac- 
ture by supposing that the scapula is so inclined by the contraction of 
the trapezius and the pressure of the clavicle upon the coracoid process-, 
acting in opposite directions, that its inferior angle is abducted, the cora- 
coid depressed, and the acromion elevated and drawn inward over the 
outer end of the clavicle. 

The autopsy in Melle's case and experiments upon the cadaver show 
that the ligaments uniting the acromion and coracoid to the clavicle are 
completely ruptured ; the clinical facts show that the displacement of the 
clavicle is not only downward and outward under the acromion but also 
backward to an extent that leaves the acromial facet entirely in front of 
the clavicle. This is perhaps to be accounted for by the presence of the 
head of the humerus, w T hich opposes a displacement directly downward ; 
and the same anatomical fact may explain the coincident dislocation of 
the humerus in Melle's case. The only other complications observed 
clinically are fracture of the surgical neck of the humerus, in one of Morel - 
Lavallee's cases, and simultaneous dislocation of the other end of the 
clavicle, in Newman's ; but in experiments upon the cadaver fractures of 
the acromion and of the clavicle have been met with. In Melle's case 
the meniscus accompanied the clavicle. 

Symptoms. — The pain at the moment of the accident may be severe 
or slight ; voluntary movements of the arm are interfered with, and 
sometimes entirely prevented; and in one case (Allen) there was persistent 
numbness and tingling in the arm and hand, indicative of pressure upon 
the brachial plexus. The appearance of the shoulder is affected by the 



SUBCORACOID DISLOCATION. 193 

sinking of the acromion and rising of the inferior angle of the scapula so 
that it appears to be inclined forward. The shoulder is usually approxi- 
mated to the side of the head, but may be on a lower level than the 
opposite one because of the inclination of the trunk. The central portion 
of the clavicle may be depressed below the level of the soft parts in front 
and behind ; its sternal end projects sharply forward, and its acromial 
end can be traced with the finger to the point where it engages under the 
acromion a little behind the articular facet on the latter. An obscure 
part of the description of Tournel's case, which Malgaigne found unin- 
telligible, may possibly mean that the end of the clavicle passed entirely 
under the acromion and projected beyond its outer border. 1 The outline 
of the acromion and its empty articular facet can usually be traced with 
the finger, although in one case the swelling of the soft parts was very 
great. 

The 2^ognosis is favorable; in Tournel's case, in which reduction was 
not attempted, the patient had good use of the limb ; in Melle's a new 
joint had formed between the under surface of the acromion and the 
upper surface of the clavicle, but the effect upon the functions of the limb 
cannot be known, for a dislocation of the humerus coexisted. In all the 
other cases in which the record is sufficiently complete reduction was 
easily effected with or without the aid of anaesthesia, and there appears 
to have been no tendency to recurrence except in one case. 

Treatment. — Reduction is made by drawing the shoulder outward and 
backward, the arm being kept parallel to the trunk, and counter-exten- 
sion being made by a bandage passed around the chest. Morel-Lavellee 
made traction from the wrist or elbow with the arm abducted, but this 
position of the limb is less favorable. Tournel reduced by placing his 
knee between the shoulders and drawing them forcibly backward ; and 
Uhde did likewise, at the same time pressing the clavicle forward. The 
arm should be fixed against the trunk, and the forearm supported by a 
body bandage and sling. 

SUBCORACOID DISLOCATION. (LuXATIO CLAVICUL.E SUBCORACOLDEA.) 

Authority for the belief that this singular displacement has ever been 
clinically observed rests upon the statements of two surgeons, Godemer 
and Pinjon. Godemer met with his first case in 1833 and with four 
others in the following five years ; Pinjon reported a sixth example in 1842. 
Godemer's cases were reported to the Societe medicale d'lndre et Loire, 
and published in 1843 ; his paper was republished by Malgaigne in the 
Revue medico-chirugicale de Paris, 1847, vol. 2, p. 155 ; Pinjon's case 
was reported in the Journal de medecine de Lyon, 1842, vol. 3, p. 58. 
All systematic writers upon the subject are agreed in viewing these reports 
with much suspicion because of their remarkable similarity in detail and 
of the great anatomical obstacles to the production and maintenance of 
the displacement. 

The features, as described by Malgaigne, are as follows : Four of the 

1 The phrase is: " L'epanle presentait en outre deux saillies ; une interne et 
superieure formee par l'acromion, l'autre externe et inferieure formee par l'extremite 
externe de la clavicule." 

13 



194 DISLOCATION OF BOTH ENDS OF CLAVICLE. 

six patients were between the ages of sixty-seven and seventy-one years; 
the remaining two are described as adults. In every case the injury was 
caused by a fall upon the shoulder. 

The symptoms were : 1st. More or less pain and a large ecchymosis in 
the coraco-acromial region. 

2d. A depression at the normal position of the clavicle; this bone was 
found to be inclined downward and outward, and its acromial end lodged 
in the axilla. 

3d. The coracoid and acromion processes were prominent under the 
skin. 

4th. The shoulder was inclined downward and forward ; the inferior 
angle and posterior border of the scapula formed posteriorly a projection 
which disappeared when the shoulder was carried upward and backward. 

5th. The arm was dependent, but could be easily moved in any direc- 
tion except upward and inward. 

Godemer made reduction in three cases by grasping the clavicle and 
disengaging it from under the coracoid process, while an assistant forced 
the shoulder backward and outward. In his other two cases the swelling 
prevented reduction before the third day. Pinjon failed to reduce because 
of the fainting of his assistant ; the next day reduction was made by a 
" bone-setter." 

C. Simultaneous Dislocation of both Ends of the Clavicle. 
(Total Dislocation.) 

The recorded cases of this injury are now ten in number: Richerand, 1 
Morel-Lavellee, 2 North, 3 Hutchinson, 4 Haynes, 5 Col, 6 Lund, 7 Rombeau, 
Hulke, 9 and Newman. 10 Seven of the patients were males, three females ; 
their ages ranged between thirteen and forty years. 

Haynes's patient, a weakly girl, thirteen years old, produced the dis- 
location while washing the back of her neck with the hand of the affected 
side ; there was a complete dislocation forward of the sternal end, and an 
incomplete dislocation upward of the acromial end of the clavicle. " 

In all the other cases the cause was external violence, usually very 
great. The mode of production is varied, the most common form 
appearing to be force exerted along the transverse axis of the shoulders, 
and pressing forward the one that suffers the injury. Thus, Col's 
patient, a muscular girl, seventeen years old, while engaged in unloading 
a dray was caught between its shaft and a wall, the pressure being 
received upon the two shoulders, with a movement of torsion of the left 
one forward ; the left clavicle was dislocated, its sternal end resting on 

1 Richerand: Arch. gen. de Med., 1831, vol. 25, p. 108; reported by Porral, his 
interne. 

2 Morel-Lavallee : Bull, de la Snc. de Chir., 1859, vol, 9, p. 361. 

3 North : N. Y. Med. Record, 1866, vol. i. p. 79. 

4 Hutchinson: Lancet, 1871, ii. p. 711. 

5 Havnes: British Med. Journal, 1872, i. p. 99. 

6 Col : Gaz. des Hopitaux, 1872, p. 893. 

7 Lund : British Med Journal, 1874, i. p. 106. 

8 Rombeau : Bull. Gen de Therapeutique, 1874, vol. 86, p. 537; reported by Gros. 

9 Hulke: Lancet, 1885, ii. p. 245. 10 Newman: Ibid., p. 524. 






DISLOCATION OF BOTH ENDS OF CLAVICLE. 195 

the front of the sternum, and its outer end on the acromion. Hutchin- 
son's patient was caught and rolled along between a locomotive and a 
platform ; Morel- Lavallee's had his shoulder caught between the wheel of 
a cart and a pile of lumber ; Lund's, while resting his left shoulder 
against a gate, was struck by the end of the shaft of his wagon upon the 
back of the right shoulder, and the right clavicle was dislocated. North's 
patient fell backward from a stool, striking on the shoulder ; in this case 
the outer end of the clavicle was dislocated forward. Rombeau's patient 
was struck on the back by a locomotive ; Richerand's patient fell from 
the third story of a building, striking upon the top of his shoulder ; 
Newman's fell with a falling building, and Hulke's was knocked down 
by a horse. 

The sternal end has always been displaced forward, and the only addi- 
tional change in position that is mentioned is, in Morel-Lavallee's case, 
that it had moved rather upward than downward. The acromial end was 
displaced backward in four cases (once to a distance of three finger- 
breadths), upward and outward twice, and once each forward and out- 
ward, downward, and incompletely upward. In Hutchinson's case the 
displacement is not described further than by saying that "when pressure 
was made on either end of the dislocated bone the other extremity rose 
perceptibly and protruded the skin." 

In six of the cases reduction of both dislocations was effected and 
maintained, and the patients recovered with good use of the limb and 
but little deformity ; in some of them mention is made of more or less 
persistent projection of the sternal end. Morel-Lavallee was unable to 
reduce the dislocation of the outer end, although he made direct traction 
upon it with a hook introduced through the skin. Lund, with the aid 
of chloroform, could only bring the bone "into fair position;" at the 
end of ten days the ends were found "fixed in their new position." In 
Newman's case, dislocation of the outer end under the acromion, reduc- 
tion was impossible; the patient withdrew from the hospital on the tenth 
day, and remained disabled. The result in Hutchinson's case is not 
recorded. 

Treatment — Reduction has usually been effected by drawing the 
shoulder Outward and backward, and recurrence prevented by immo- 
bilizing it in a suitable position by means similar to those employed 
when the dislocation involves either end alone. Hulke used a gutta- 
perch a splint moulded over the clavicle and bound down by a bandage 
that crossed the shoulders and was made fast in front and behind to 
another about the waist. 



CHAPTEK XVI. 

DISLOCATIONS OF THE SHOULDER. 
ANTERIOR DISLOCATIONS *, SUBCORACOID, INTRACORACOID. 



Anterior Dislocations. 

Anatomy. — The bony surfaces which enter directly into the com- 
position of the shoulder-joint are the glenoid cavity of the scapula and 
the postero-internal half of the globular head of the humerus. The 
former is of irregularly oval shape, the more pointed end above and the 
broader one below, and is slightly concave, being deepened by a low 
fibro-cartilaginous rim, which is continuous throughout with the capsule, 
and above also with the tendon of the long head of the biceps. The 
cavity looks outward and forward in a direction nearly midway between 
the sagittal and frontal planes of the body when the scapula occupies its 
usual position, and changes its direction as the scapula is moved forward 
or backward around the chest, or is drawn upward or downward, or is 
rotated. 

Against this shallow surface the head of the humerus rests, being held 
in place by atmospheric pressure, the tonicity of the muscles, and the 

tension of thickened portions of the capsule 
in different positions of the limb. On the 
outer and anterior portion of the upper end 
of the humerus is the greater tuberosity, 
bounded internally in front by the bicipital 
groove which lodges the long tendon of the 
biceps in its passage downward and has upon 
its inner side the lesser tuberosity. Between 
the upper margins of these tuberosities and the 
globular articular head is a shallow groove, 
the anatomical neck. 

The acromion and coracoid processes lie 
above, the one on the outer, the other on the 
side, and the strong coraco-acromial 
them closes in the upper 
part of the joint, but is separated from its 
cavity, as are also the two processes, by the 
interposed capsule and the tendon of the 
supraspinatus. 

The surface of the head of the humerus 
that is covered by articular cartilage is 
about one-third of that of a sphere, and 
the axis passing through its centre meets the long axis of the shaft at 
an angle of about 130°. The linear extent of the glenoid fossa, including 




inner 

ligament uniting 



S ' F 

To show the relations of the hu- 
merus and scapula. X, the lesser 
tuberosity. F and S indicate the 
frontal and sagittal planes. 



ANTERIOR DISLOCATIONS OF SHOULDER. 



197 



its fibrocartilaginous rim, on a horizontal section is less than half as 
great as that of the head of the humerus ; on a vertical section it is 
about two-thirds as great. The head of the humerus, therefore, simply 
rests against the fossa, and its displacement is but slightly opposed by 
the conditions of contact between them. The muscles which are most 
closely associated with the joint are the supraspinatus, infraspinatus, 
and teres minor, attached to the greater tuberosity in the order named 
from above downward, and the subscapulars, which, arising from almost 
the whole of the costal surface of the scapula, passes forward, broadly 
covering the inner side of the joint with its fibres and tendon, to be 



Fig. 38. 





Horizontal section through the shoulder-joint ; A, in inward, B, in outward rotation. (Hexle.) 



attached to the lesser tuberosity. The tendon of the long head of 
the biceps, starting from the upper margin of the glenoid cavity, passes 
upward and forward over the head of the humerus and then down the 
bicipital groove, carrying with it a prolongation of the synovial membrane 
of the joint. The deltoid, from its broad origin on the spine of the 
scapula, the acromion, and the clavicle, covers the joint superficially on 
its posterior, external, and anterior aspects ; and the coraco-brachialis, 
the short head of the biceps, and the great vessels and nerves lie upon 
its inner side. 

The capsule extends from the free margin of the fibro-cartilaginous rim 
of the glenoid fossa, or from the surface of bone immediately outside of 
it, to the anatomical neck of the humerus. At the upper part its scapular 
insertion is at the base of the coracoid process and separated from the 
glenoid fossa by the tendon of the biceps ; on the posterior and inner 
portion of the humerus it extends somewhat beyond the cartilaginous 
surface along the projection upon which the head rests. Between the 
two tuberosities the svnovial membrane bv which it is lined is prolonged 
down the bicipital groove, and is reflected over the long tendon of the 
biceps. The capsule is reinforced at some points by thickenings of itself 
which are known as ligaments and by the tendons of the scapular muscles ; 
on the inner side it is perforated by the tendon of the subscapularis, and 
there shows a gap through which the cavity of the joint communicates 
with the subscapular bursa, a large pouch lying against the inner side of 
the neck of the scapula and the root of the coracoid process, between 
them and the upper part of the subscapularis. This opening lies just in 
front of the upper part of the anterior (inner) margin of the glenoid 
fossa, has the form of a slit or crescent, and is usually large enough to 



198 



ANTERIOR DISLOCATIONS OF SHOULDER. 



admit the end of the finger. When the synovial membrane has been 
dissected away the gap has the form shown in Figs. 39 and 40, and is 
partly occupied by the tendon of the subscapulars. The portion of the 



Ftg. 



Supragleno-suprohumeral 
Ligament* 



Subs cap ularis. 




Latis.Dorsi- 



The shoulder-joint ; from in front. (Farabeuf.) 



capsule which forms its upper margin is called the gleno-humeral liga- 
ment, or, to adopt the subdivisions described by Farabeuf, 1 the supra- 
gleno-suprahumeral, the portion forming the lower margin is the supra- 



Fig. 40. 




The interior of the shoulder-joint from behind. (Farabeuf.) 1, coraco-humeral ligament. 2, supra- 
gleno-suprahumeral ligament. 3, supragleno-nrachunieral ligaments. 4, praogleno-subhumeral ligament. 
5, upper edge of the tendon of the subscapulars ; 5', its lower part. B, biceps tendon. C, coracoid. 
E, spine of scapula. G, glenoid fossa. 

gleno-prgehumeral, and the portion immediately beloAV the latter is the 
prcegleno-subhumeral. These different portions are shown in Figs. 
39 and 40, which are copied from Farabeuf s paper. Of them the one 

1 Farabeuf: Bull, de la Soc. de Chirurgie, 1885, p. 391. 



ANTERIOR DISLOCATIONS OF SHOULDER. 199 

that forms the lower margin of the gap, the supragleno-prsehumeral, is 
often of slight strength and underlies and is intimately adherent to the 
tendon of the subscapularis. 

The coraco-humeral ligament is a strong wide band extending from 
the root and outer border of the coracoid process over the top of the joint 
to the neck of the humerus above the greater tuberosity, and is intimately 
connected with the capsule and the tendon of the supraspinatus. It is 
thought to play an important part in determining the position taken by 
the limb when dislocated, and the manoeuvres by which the dislocation 
can be reduced. 

The tendon of the supraspinatus passes between the acromion and the 
head of the humerus and is attached to the upper part of the greater 
tuberosity ; it is blended with the capsule and is separated from the 
acromion by a bursa. Below it come the tendons of the infraspinatus 
and teres minor, passing to the lower and middle facets respectively and 
also blended with the capsule. 

Outside the capsule is a loose layer of connective tissue which separates 
it and the tendons of the outer muscles from the under surface of the 
deltoid; within the layer is the subdeltoid bursa, extending under the 
acromion, which deserves special mention because of the fact that when 
the tendon of the supraspinatus is torn away from its attachment in a 
dislocation and retracts under the acromion with the adherent capsule, 
this bursa is thereby opened and placed in communication with the 
cavity of the joint, and the upper portion of the capsule is thus greatly 
lengthened. The influence of these new conditions in favoring recurrence 
of dislocation has been discussed in Chapter III. 

With respect to the nerves and arteries it is only necessary to speak 
of the circumflex nerve and of the arterial branches which pass outward, 
the two circumflex and the subscapular. The circumflex nerve winds 
around behind the neck of the humerus to its outer side, to be distrib- 
uted to the deltoid muscle and to the integument covering it. It may 
be so injured in a dislocation that the deltoid will be paralyzed, perhaps 
permanently. 

The circumflex and subscapular arteries pass outward to be distributed 
among the muscles of the scapula and upper part of the arm ; when in a 
dislocation the head of the humerus presses the axillary artery inward, 
those branches are put upon the stretch because they are prevented by 
the attachment of their branches to the tissues from moving inward as 
freely as the main trunk does, and consequently they may be ruptured 
or torn away from the side of the main artery. This accident may be 
the consequence of the dislocation itself, or of the efforts to reduce it. 

The movements of the joint are not only very free but they are also 
effected by the gliding of one surface over the other, not by simple 
rolling, and consequently the capsule is loose and is thrown into folds on 
the side toward which the limb is moved. Above and on each side these 
folds are drawn back by the attached muscles in the line of their con- 
traction and thus are kept from being caught between the articular 
surfaces ; meanwhile, on the opposite side of the joint the capsule is 
made tense not only by the separation of its scapular and humeral points 



200 ANTERIOR DISLOCATIONS OF SHOULDER. 

of attachment, but also by the pressure against its inner surface of the 
head of the humerus around which it is stretched. 

The movements which are most frequently concerned in the production 
of a dislocation are outward rotation and abduction. In the latter the 
elbow is raised directly outward or outward and forward from the side of 
the body by the action of the deltoid, the plane in which it moves being 
more or less exactly that which would be represented by the prolongation 
of the broad surface of the shoulder-blade. As the movement is made, 
the head slides downward on the glenoid fossa, the long head of the 
triceps, the lower part of the subscapularis, and the lower and inner 
portion of the capsule are made tense, and the movement is arrested 
when the top of the greater tuberosity comes into contact with the upper 
margin of the glenoid fossa, and the side of the shaft close below the 
tuberosity touches the acromion. If the movement is now continued, and 
the arm raised to the side of the head, it is effected by the rotation of 
the scapula and the elevation of its outer portion. If, on the other hand, 
the movement is continued while the scapula is kept stationary, the centre 
of motion is transferred to the point of contact between the humerus and 
the edge of the acromion, and the head of the bone is forced downward 
against the already tense capsule and ruptures it at its lower and inner 
portion, there where it presses directly against it. 

In outward rotation when the arm is hanging by the side or is but 
slightly abducted the movement is arrested by the tension of the capsule 
on the inner side, and at the same time the lower and outer part of the 
greater tuberosity comes into contact with the outer lip of the glenoid 
fossa ; if the movement is then continued the capsule yields, but the head 
does not become dislocated unless some other force intervenes to press it 
inward through the rent that has thus been made. 

In all the other movements similar conditions are found, and disloca- 
tions following them are less frequent only because the movements are 
themselves less frequently carried beyond the limits set by the structure 
of the joint. Thus, adduction and rotation inward are checked by con- 
tact of the arm with the body before the capsule is put upon the stretch, 
and extension of the arm behind the axillary line must be carried very 
far before a new fulcrum is found, and is also a movement that is rarely 
produced or exaggerated by external violence. 

Statistics. — The great frequency of dislocation of the shoulder is fully 
explained by the structure of the joint and by its exposure to the dislo- 
cating action of direct and indirect violence. This frequency is so great 
that dislocations of the shoulder are about as numerous as all the other 
dislocations of the body combined. The table of statistics given in Chapter 
I. show percentages varying from 46 to 60 of all dislocations. Malgaigne's 
statistics of 489 cases contain 321 of the humerus, more than 65 per 
cent.; Gurlt's collection of 907 cases in the hospitals of Berlin, Paris, 
and Philadelphia contain 563 of the shoulder, 58 percent.; Bardenheuer 1 
saw 20 in a total of 37 cases treated in one year, 54 per cent. Kron- 
lein's statistics, which are especially valuable because they are made up 
from both hospital and polyclinic records, give a total of 207 dislocations 

1 Bardenheuer: Deutsche Chirurgie, Lief. 63 a, p. 279. 



ANTERIOR DISLOCATIONS OF SHOULDER. 



201 



of the shoulder, of which 184 were in males and only 23 in females ; of 
Malgaigne's 370 cases 97 were in women ; classified according to age and 
sex they are as follows : 

Table X.— Dislocations of the Shoulder. 

Malgaigne. 







Hotel Dieu. 


St 


Louis. 






Age. 


Male. 


Female. 


Male. 


Female. 


Tota 


5 to 15 


years . 


2 


1 




1 


4 


15 «' 25 




. 31 


2 


s 




36 


25 " 45 


u 


. 60 


21 


15 


1 


97 


45 " 60 


Li 


. 80 


27 


13 


4 


124 


61 " 70 


(I 


. 44 


23 


7 


4 


78 


70 


" 


. 17 


13 


1 




31 



Krbnlein. 

Age. 

11 to 20 2 

21 " 30 . . . ... . .55 

31 " 40 45 

41 " 50 48 

51 " 60 36 

61 " 70 19 

71 " 80 . . . . . . . .2 

Both show that the injury is rare in youth and old age, is most frequent 
in middle life, and is much more frequent in men than in women. The 
relative frequency at the different ages, established by taking into account 
the percentages of the total population belonging to those ages, differs 
somewhat from the actual frequency, the maximum being found above the 
age of fifty years. The proportions calculated from Kronlein's statistics 
with the aid of the relative numbers of the population at the different 
ages, as given in Table V., Chapter I., are 5, 9, 11, and 12 respectively 
for the decades from 31 to 70. This relatively greater frequency 
in advanced years is much more marked in women than in men, 
a fact which is to be explained by the greater exposure to violence 
incident to the occupations and habits of men in middle life. It indi- 
cates, I think, that a much larger proportion of the dislocations in 
advanced life are due to falls while walking than in middle life, since 
that is an accident to which both sexes are more equally exposed than 
they are to others. 

The relations pointed out by Kronlein as existing between dislocations 
of the shoulder and those of the elbow and fractures of the clavicle are 
interesting. His statistics show that during the first two decades of life, 
a period in which dislocations of the shoulder are rare, dislocations of the 
elbow and fractures of the clavicle are most frequent. Thus, of 109 
dislocations of the elbow contained in his table, 80 of the patients 
were under twenty years of age, and of 100 cases of fracture of the 
clavicle collected by him 70 of the patients were under ten years of 
age ; while of 207 dislocations of the shoulder none of the patients was 
less than ten, and only 2 less than twenty years old. He thinks frac- 
tures of the clavicle are in childhood the equivalent injury of dislocations 



202 ANTERIOR DISLOCATIONS OF SHOULDER. 

of the shoulder by direct violence in middle life, and dislocations of the 
elbow the equivalent injury of dislocations of the shoulder by indirect 
violence. He further quotes investigations made by Kiistner as showing 
that separation of the epiphysis in early life, and especially when pro- 
duced by obstetrical manipulations, is the equivalent of dislocation at 
other ages, since it is caused by the same mechanism, the forcing of the 
limb beyond the range of normal motion ; the epiphysis separates more 
easily than the capsule ruptures. 

Classification. — The head of the humerus in leaving the joint may 
pass at first upward or downward, backward or forward, and may come 
to rest in any one of a great number of positions. The classification of 
the varieties is beset with much difficulty, because of their number, 
because of the frequency and importance of the secondary displacements, 
and, last though not least, because of the number of classifications that 
have already been made and are more or less current. The confusion 
has been further increased by the application of the same or very similar 
terms to different varieties by different authors. With the rare disloca- 
tions backward, and the still rarer ones upward, there is no difficulty ; 
the uncertainty arises in connection with those in which the head of the 
humerus has passed across the anterior lip of the glenoid fossa. A brief 
account of some of the classifications and terms heretofore and still in use 
will show their differences and resemblances, and may serve as a conve- 
nient introduction and preparation for the classification that must follow. 

Sir Astley Cooper's classification, upon which those now in use in 
England and America have been in the main constructed, recognized 
four kinds of dislocations : 1. Downward and inward into the axilla ; 2. 
Fonvard, the head of the humerus lying under the clavicle on the sternal 
side of the coracoid process ; 3. Backward ; 4. Partial inward, the head 
resting against the outer side of the coracoid process. It is apparent, 
from his description, that the first and fourth included the common, fre- 
quent cases, those which are now generally termed "subglenoid," or 
" into the axilla," and " subcoracoid," respectively. 

A few years later Malgaigne followed, also with four principal forms, 
but only one of them the same as Cooper's. His grouping is as follows : 

(1. Subcoracoid, complete ; quite common. 
2. Subcoracoid, incomplete; rare. 
3. Subglenoid ; rare. 

4. Intracoracoid; most common of all. 

5. Subclavicular; rare. 

6. Subacromial ; rare. 

7. Subspinous ; very rare. 

Dislocations upward 8. Supracoracoid ; only two cases known. 



Dislocations inward. 
Dislocations backward 



All these titles are now in general use ; but while the last four, and 
perhaps the second also, are still used to designate the forms which he 
designated by them, the others have been used w r ith different, sometimes 
with widely different, meanings. The first form, the complete subcora- 
coid, was " characterized by the projection of the head of the humerus in 
the axilla, and its position exactly below the coracoid process ;" it would 
be included in Cooper's first group, dislocation dowmw T ard into the axilla. 



ANTERIOR DISLOCATIONS OF SHOULDER. 203 

His second subdivision, incomplete subcoracoid, was the same as Cooper's 
fourth, partial dislocation inward. His third, subglenoid, was one con- 
cerning which he seems to have been far from having very precise notions ; 
he had seen only one case, and had been able to collect only eleven others, 
and of these the symptoms differed widely, the head of the humerus being 
described as raising the anterior wall of the axilla in one case, and the 
posterior in another, as resting against the second intercostal space in 
one, and against the third in another, and even as having perforated the 
wall of the chest and lodged within it. The one feature which they had 
in common, and which he gives as pathognomonic, was that the head of 
the humerus was not immediately below and in contact with the beak of 
the coracoid process, but was separated from it by a greater or less 
interval. Apparently the class was created simply to collect together 
the odds and ends, the irregular cases that were not subcoracoid ; and 
the idea which suggested the name given to it was that the primary dis- 
placement took place more directly downward than in the preceding 
varieties. It will be seen that the name has since been applied to a very 
much larger proportion of cases. 

His second main division embraced two varieties, the intracoracoid and 
the subclavicular. Concerning the latter there is no misconception ; the 
term has remained in use, and with the same meaning. The group is 
made up of those cases in which the head of the humerus has passed 
entirely to the inner side of the coracoid process, and lies below the 
clavicle. But the other term, intracoracoid, is generally employed in a 
much more restricted sense than by Malgaigne. By it he designated 
the greatest number of dislocations/more than two-thirds of those he saw 
at the Hopital St. Louis ; he applied it to those in which the head of 
the humerus, while still remaining under the coracoid process, overlapped 
it on the inner side by more than half its own diameter. Most of such 
cases are now termed subcoracoid, and only those in which the head has 
passed almost, if not entirely, to the inner side of the process are called 
intracoracoid. 

The tendency of the more recent French and German writers is to 
make a single group of all the dislocations in which the humerus passes 
to the anterior side of the scapula, containing four or more subdivisions 
or varieties, two of which, the subclavicular and intracoracoid, in the 
narrower sense, are accepted by all. Of the remaining two principal 
ones, the subcoracoid and the subglenoid, the former is made to include 
the great majority, and the subglenoid is either closely and distinctly 
restricted to the very rare cases in which the head of the humerus is 
displaced directly downward upon the tendon of the long head of the 
triceps, or Malgaigne's grouping is accepted with all its diversities and 
vagueness. In the former case the group is removed from the principal 
division of "anterior" or " prseglenoidal " dislocations, and made to form 
by itself another principal division, termed "dislocations downward." 

The English and American writers, as a rule, divide the same cases 
into subglenoid and subcoracoid, basing the distinction between them upon 
the clinical feature of the greater or less facility with which the head of 
the humerus can be felt in the axilla; those in which it is more promi- 
nent in the axilla are "subglenoid," those in which it is more prominent 



204 ANTERIOR DISLOCATIONS OF SHOULDER. 

behind the anterior wall of the axilla, close beneath the coracoid process, 
are " subcoracoid." The objections to this grouping are that it does not 
sufficiently distinguish between primary and secondary displacements, and 
that the clinical features upon which it rests present a complete series of 
intermediate forms, most of which might be as properly placed in one 
group as in the other. The arbitrariness and uncertainty of the decision 
are well shown by a comparison of clinical and pathological statistics. 
Thus, Hamilton and Bryant say that the subglenoid is of more frequent 
occurrence than the subcoracoid, and Erichsen says that this is the opinion 
of most English surgeons ; while, on the other hand. Flower, 1 who made 
an examination of all the specimens contained in the London museums, 
41 in number, found that in 32 the dislocation was subcoracoid, and he 
adds, that of 50 cases recently observed by him in living patients the 
same was true of " a large majority;" 2 he calls attention to the fact that 
" the great frequency of subcoracoid dislocation observed in this series 
[of specimens] does not accord with the descriptions of this injury gener- 
ally given in the standard surgical works of the country." A few years 
later, in the article on Injuries of the Upper Extremity which he pre- 
pared in connection with Mr. Hulke for Holmes's System of Surgery, 
Mr. Flower made a classification in which the influence of this important 
investigation is apparent. It is as follows : 

1. Subcoracoid. Forward and slightly downward. On to the neck 
of the scapula, in front of the glenoid fossa, and immediately below the 
coracoid process. Common. 

2. Subglenoid. Downward and forward. Head of the humerus in 
front of the inferior costa [border] of the scapula, below the glenoid fossa. 
Rare. 

His remaining three divisions are Subclavicular, Supracoracoid, and 
Subspinous, the latter including Malgaigne's sixth and seventh. 

Turning now to the pathological data, to the recorded results of post- 
mortem examinations and experiments upon the cadaver, and confining 
our attention for the moment to the forms mainly in dispute, the disloca- 
tions forward (or inward) and downward, and to the points that affect the 
position of the head of the humerus, the following facts appear : 

The head of the humerus, when it passes across the anterior edge of 
the glenoid cavity, must, as a glance at Fig. 37 shows, move somewhat 
downward so as to get below the beak of the coracoid process ; the position 
of the limb that most favors the production of dislocation is abduction 
with or without external rotation. The inner and lower portion of the 
capsule, being pressed upon by the head of the humerus, tears between 
the tendon of the subscapularis and the triceps, the rent being small or 
large and varying greatly in extent and direction in the different cases, 
but it is always on the anterior and inner side, and the head passes more 
or less completely through it. If the movement is more directly forward 
and inward and to a less degree downward, as in dislocations by direct 
violence received on the outer side of the shoulder, the head of the bone 

i Flower: Trans. London Path. Soc, 1861, vol. 12, p. 179. 

2 The number is given as 41 in his article on Injuries of the Upper Extremity in 
Holmes's System of Surgeiy. 



ANTERIOR DISLOCATIONS OF SHOULDER. 205 

pushes the subscapularis muscle before it and lodges close under the cora- 
coid process and between that muscle and the edge of the glenoid cavity. 
In this case no secondary displacement ensues, and the form would be 
classed as subcoraeoid by all. If the movement is forcible and prolonged 
the subscapulars may be torn entirely across and the head may pass 
through it and come to rest on the side of the thorax under the clavicle ; 
or, as in a case quoted by Malgaigne, it may pass over the upper border 
of the subscapularis and come to rest at the same point. If, on the other 
hand, the primary movement downward has been more marked, as in dis- 
locations effected by hyper-abduction of the arm, the head either passes 
below the subscapularis or tears its lower portion, and then, as the elbow 
is lowered the head rises, pressing the subscapularis or its untorn portion 
upward and remaining separated by it from the coracoid process. The 
extent and direction of this movement of the head are determined largely 
by the resistance of the untorn portions of the capsule, notably the outer 
and anterior part, which, by preventing the further descent of that part 
of the humerus to which they are attached, compel the head to move 
upward as the elbow descends. Other factors are found in the muscles ; 
if the head lies under an untorn subscapularis its distance below the cora- 
coid process will be greater than when it lies under only the upper por- 
tion of the muscle, and if in addition it has passed under the teres major 
or downward as far as the lower border of the pectoralis major the arm will 
remain widely abducted or even with the elbow above the head (luxatio 
erecta). Or, departing still further from what is usual, it may perhaps 
even turn backward after it has left its socket and pass under the long 
head of the triceps to lodge behind the glenoid cavity, the alleged sub- 
tricipital dislocation. 

Fig. 41. 



TfNDOH 
OfL Tff/<£PS- 



To show the range of positions that may be taken by the head of the humerus after primary displacement 
forward or downward in any of the directions between the arrows. 

The head of the humerus rests against the inner side of the head or 
neck of the scapula at any point between its junction with the broad 
axillary border, or inferior costa, and the middle of the anterior lip of the 
glenoid fossa, and it may lie either directly against the edge of this lip or 
further back on the side, as is clearly shown by the specimens of old, 



206 ANTERIOJl DISLOCATION'S OF SHOULDER. 

unreduced dislocations preserved in the museums. And according as it 
occupies one or the other position it will be more or less prominent in the 
axilla or more or less clearly seen and felt behind the pectoralis major 
beneath the coracoid process. The diagram in Fig. 41 shows the range 
of positions that may be taken by the head after primary displacement 
forward or downward. 

It is evident, then, that the position in which the head of the bone is 
found bears only a limited relation to the point at which it left the joint, 
and that a classification which is sharply; made upon this position is not 
only arbitrary and uncertain for a large number of cases, but also invites 
inattention to points that have an important bearing upon a safe and easy 
reduction. 

It is desirable that a classification should not deal minutely with 
unimportant variations, and that instead of multiplying divisions it 
should rather gather into few groups those varieties that have character- 
istic and important features in common ; and yet, as some forms differ 
widely in their symptoms from others with which they are on other 
grounds closely related, it is equally desirable to recognize and note such 
differences. The distinction made by Professor Bigelow between " regu- 
lar " and "irregular" dislocations at the hip can also be made at the 
shoulder, taking for the dislocations downward and forward the integrity 
or the rupture of the antero- external portions of the capsule as the deter- 
mining feature, but it has not the same importance in treatment. The 
following classification is, in the main, the same as that of Mr. Flower, 
above mentioned, and the later French and German writers. It differs 
from that of the majority of the English and American writers in restrict- 
ing the group of the "subglenoid" and correspondingly enlarging that 
of the "subcoracoid" dislocations. 

( Subcoracoid ; very common. 
Anterior . . . < Intracoracoid ; exceptional. 
( subclavicular. 

[Subglenoid; uncommon. 
Downward . . . < erecta ; very rare. 

( subtricipital.(?). 

-d , . f Subacromial ; rare. 

Postenor • • • J Subspinous ; very rare. 

Upward . . . Supraglenoid ; very rare. 

The names of the four principal divisions indicate the direction of the 
primary displacement; those of the subdivisions the position in which the 
head of the bone lodges, with the exception of the erecta, which takes its 
name from the attitude of the limb, and the subtricipital, which rather 
indicates the route traversed by the head than the position finally taken 
by it. Between the anterior and the downward the division cannot be 
sharply made, and in many of the cases included among the first the 
primary displacement has more of the downward than of the anterior 
feature, but it is believed that by enlarging the subcoracoid class so that 
it will include all but the lowest of the lower forms, by extending its 
range so that it will distinctly include the lower as well as the higher 
primary displacements, the necessity of abducting the arm to effect reduc- 



ANTERIOR AND DOWNWARD DISLOCATIONS. 207 

tion in those cases in which the secondary displacement upward is marked 
and might otherwise lead into error will be less liable to be overlooked. 
The difficulty of distinguishing between the subglenoid and the lowest of 
the subcoracoid will arise in only a very limited number of cases and will 
be without practical importance; at the most it will be merely a question 
of nomenclature. 



Anterior (and Downward) Dislocations. 

1. Subcoracoid. 

2. Intracoracoid, subclavicular. 

In these dislocations the head of the humerus passes across the anterior 
lip of the glenoid fossa, taking at first a direction that is forward and 
inward and more or less downward ; it may subsequently move upward 
or further inward. The class includes two subdivisions, the subcoracoid 
and the intracoracoid, of which the latter is here made to include also 
the more marked dislocation inward known as the subclavicular. 

The class embraces the subcoracoid, partial and complete, of all 
authors, most of the subglenoid of most English and American authors, 
and the intracoracoid and subclavicular of all. The terms " axillary 
dislocations " and " dislocations into the axilla " are applied by some to 
cases that are here called subcoracoid, and the term ''pectoral" to the 
intracoracoid. 

I. Subcoracoid Dislocations. 

In this form, which includes a large majority of all cases, the head of 
the humerus lies under and in close proximity to the beak of the coracoid 
process, or at a distance below it that may equal or even exceed a finger 
breadth. The centre of the head may be either directly below the beak 
of the coracoid processor on its outer or inner side. If more than three- 
fourths of the transverse diameter has passed to the inner side of the 
coracoid the dislocation is termed intracoracoid. The class, therefore, is 
continuous with the subglenoid below and with the intracoracoid on the 
inner side, and the separation from them is arbitrary and artificial but is 
justified by custom and convenience in description. 

Malgaigne showed, as early as 1835, that in some cases the articular 
surface of the head of the humerus rested on the anterior edge of the 
glenoid fossa, and such he termed " incomplete." Subsequently, in his 
volume on dislocations, he was able to reinforce his demonstration by 
additional clinical observations and by an autopsy in a recent case. The 
formation of a separate class composed of such cases seems unnecessary 
and even undesirable, for they differ from the complete ones only in 
degree, and the difference is both slight and without practical importance; 
the symptoms are like those of complete dislocation, the bone is fixed in 
its new position, and aid is required to replace it in the joint. More- 
over, in some the diagnosis (differential, between complete and incomplete) 
can only be made at the autopsy. This was true even of one of Mal- 
gaigne's cases. 

The injury maybe produced by direct or indirect violence, a blow upon 



208 ANTERIOR AND DOWNWARD DISLOCATIONS. 

the outer and upper part of the shoulder or hyperabduction of the arm, 
or by muscular action. When produced by direct violence the displace- 
ment is usually in a direction that is only sufficiently inclined downward 
to enable the head to pass below the coracoid process ; in a unique case 
reported by Kronlein 1 the blow was received from above upon the acromion 
and only dislocated the humerus after it had broken that process. The 
extent of the displacement inward is affected partly by the force of the 
blow and the extent of the laceration of the capsule, and partly by the 
contraction of the muscles that adduct the limb. 

Dislocations by indirect violence are the most common, the force acting 
to produce hyperabduction of the limb. The elbow can be raised to the 
height of the shoulder, while the scapula remains fixed in its habitual 
position, the movement taking place solely intthe shoulder-joint, but 
extension of the movement can be normally effected only by a change in 
the position of the scapula by which its articular surface, the glenoid 
fossa, is directed upward. The hyperabduction which produces the dislo- 
cation takes place in the shoulder-joint, and consequently if the scapula 
is fixed in a low position the dislocation may take place even when the 
movement carries the elbow but little, if at all, higher than the shoulder. 
On the other hand, if the scapula moves freely the elbow may, as all 
know, be safely brought as high as the head. In short, hyperabduction 
of the joint sufficient to cause dislocation can exist while the elbow is at 
or even below the level of the shoulder. The auxiliary fixation of the 
scapula is commonly effected by the contraction of the muscles in an 
effort to control or prevent the elevation of the arm, and it can take place 
not only when the scapula is at any point between that which it occupies 
when the limb is at rest and dependent and that of extreme elevation of 
the limb, but also when its anterior portion is depressed below the position 
of rest. This is the explanation, in part, of some cases in which the 
dislocation has occurred while the elbow was lower than the shoulder ; 
the associated factor is the contraction of the muscles. 

Hyperabduction acts, as has been already described, by bringing the 
outer side of the upper end of the humerus into contact with the edge of 
the acromion and thus creating a new centre of motion for the continued 
movement, the effect of which is to cause the head of the humerus to 
descend and rupture the capsule in its inner and lower portion. After 
this rupture has taken place and the upward movement of the elbow has 
ceased, the contraction of the muscles, the deltoid, pectoralis major, and 
latissimus dorsi, draws the head of the humerus inward past the anterior 
lip of the glenoid fossa, and then when the elbow is lowered the head 
rises along the inner side of the joint, for the untorn outer and anterior 
portion of the capsule is made tense and, by thus preventing the descent 
of the portion of the bone to which it is attached, compels the movement 
to take place about this portion as a centre. As the first new centre of 
motion at the edge of the acromion determines, in connection with the 
muscles, the primary displacement, so the second new centre at the outer 
and anterior attachment of the capsule determines the secondary displace- 

1 Kronlein: Deutsche Chirurgie, Lief. 26, p. 14. 



ANTERIOR AND DOWNWARD DISLOCATIONS. 209 

ment and the final position of the head of the bone and the attitude of 
the limb. 

Muscular action, the contraction of the muscles of the individual him- 
self, can produce a dislocation either by drawing the head of the bone 
directly out of its socket, or, much more commonly, by creating condi- 
tions of leverage and momentum similar to those existing in the 
production of dislocations by indirect violence. In many of the reported 
cases it is difficult to recognize the mechanism of the injury. The least 
questionable examples of dislocation effected by the direct traction of the 
muscles are those in which the injury has occurred during a convulsion. 
A considerable number of such have been reported. The examples of 
the other kind are numerous and varied, and the explanation is usually 
simple. A painter raises his arm to work upon a ceiling, an artillery- 
man to throw a shot, a patient lying in bed to free its curtain caught 
under the pillow, a woman to grasp an object hanging on the wall ; in 
such cases hyperabduction of the joint seems to be the probable cause. 
In others hyperabduction can only be invoked on the supposition that the 
contraction of the deltoid has lowered the acromion, the arm being fixed 
in a position below the shoulder, as in Bichat's case of the notary who 
dislocated his shoulder in an attempt to raise a heavy book from the floor, 
or in Volkmann's of a woman who tried to lift a heavy pot from a shelf 
at the height of her shoulder, or Malgaigne's athlete who tried suddenly 
to lift a man kneeling in front of him, or Duplay's very muscular patient 
who stumbled while descending a staircase and threw out his arm to save 
himself from falling but touched no object with it. 

In other cases the influence of muscular action is entirely indirect. 
Thus, Rickert 1 tells of a very muscular man twenty-five years old who 
received a subclavicular dislocation by resting his hand against a wall over 
his head and sneezing. Bardenheuer mentions a similar case observed by 
Saponi. In such a case the mechanism is essentially the same as in that, 
for example, in which a man supported himself with his arms outstretched 
against a wagon to receive a sack of grain which another threw down 
upon his back and thereby dislocated both shoulders. 

Even in the common cases of indirect violence, such as falls upon the 
outstretched hand or elbow, it is probable that muscular action frequently 
aids to overcome the resistance of the capsule as well as to draw the bone 
inward after this resistance has been overcome. When the arm is 
abducted and thrown back the pectoralis major and deltoid act with fall 
force, undiminished by unfavorable conditions of leverage, to draw the 
head of the humerus obliquely across the glenoid fossa, and their com- 
bined force cannot be much inferior to that of many blows which have 
proved competent to dislocate. 

The results of experiments upon the cadaver show that external rota- 
tion of the arm is in itself competent to effect rupture of the capsule, 
and several authors, following Sedillot in this, claim that external rotation 
is an important, perhaps an essential, adjunct in the production of most 
dislocations by direct impulsion. They explain its agency by assuming 
that in a fall upon the side the forearm is flexed and the elbow is thrown 

1 Rickert : Maryland Medical Journal, 1883-84, vol. 10, p. 339. 

14 



210 



ANTERIOR AND DOWNWARD DISLOCATIONS, 
Fig. 42. 




Subcoracoid dislocation, reduced ; in cadaver ; the humerus has been rotated outward to show 
the rent in the capsule. (B. Anger.) 

Fig. 43. 




Subcoracoid dislocation on a cadaver ; showing rupture of lower part of the subscapularis. (B. Anger.) 



ANTERIOR AND DOWNWARD DISLOCATIONS. 211 

backward, and that thus the elbow is pressed toward the spine, outward 
rotation of the arm. It is impossible in most cases to determine the exact 
position and attitude of the limb at the moment the dislocation occurs, 
and the relative parts taken by abduction, rotation, muscular action, and 
direct impulsion in its production. At present it can only be said that 
every one of the four has proved sufficient by itself, and that they have 
been found to cooperate in varying degrees. 

Pathology. — The results of experiments upon the cadaver are in har- 
mony with those of post-mortem examination in recent and in old cases. 
The capsule is torn at its inner and lower portion between the tendon of 
the subscapulars and the triceps, and the rent extends usually along the 
inner and lower border of the glenoid fossa for half, sometimes even two- 
thirds, of the entire periphery. In other cases the rent extends outward 
and backward, rather than upward, and near the insertion of the capsule 
upon the humerus. Exceptionally, the rent is very small, or may even 
be entirely lacking. Eve 1 reported a case of subcoracoid dislocation in 
a man thirty-six years old, who had been knocked down by a railway 
train and died a few hours afterward. The capsule was untorn but was 
separated from the anterior border of the glenoid fossa, remaining con- 
tinuous with the periosteum which was stripped up from the costal surface 
of the scapula. On the posterior surface of the head of the humerus 
was a deep vertical indentation made by impact against the anterior 
margin of the glenoid fossa. In 1880 I presented to the New York 
Surgical Society the shoulder-joint of an old man who had died of 
pneumonia a week after he had dislocated the shoulder by falling from 
the fourth story of a building. The dislocation was well marked, the 
shoulder was flattened, the head of the humerus could he distinctly felt 
in the axilla, and reduction was effected with the aid of ether. The joint 
was opened from behind, and the capsule was found untorn ; the tendon 
of the subscapulars was partly detached at its insertion, but at no point 
throughout its entire thickness, and the upper facet of the greater tuber- 
osity was broken off in several pieces but not widely separated. Such 
cases of slight or no injur j- to the capsule are classed by some writers as 
"incomplete" dislocations. 

The outer and upper portion of the capsule, when untorn, is drawn 
tightly across the glenoid fossa. 

The subscapulars muscle is sometimes simply pressed inward and 
separated from the scapula by the interposed head of the humerus, but in 
most cases it is torn more or less widely from its lower border upward, 
and its upper portion may lie upon the head of the humerus and separate 
it from the coracoid process. Occasionally, instead of being ruptured 
che muscle is torn away from its attachment to the humerus, perhaps 
bringing with it the lesser tuberosity. 

The supraspinatus is sometimes, probably often, torn from its attach- 
ment to the humerus, and the same is true in a less degree of the infra- 
spinatus, and occasionally even of the teres minor. 

The teres major is sometimes slightly torn, apparently by the partial 
passage of the head of the humerus between it and the subscapulars. 

1 Eve : Trans. Path. Soc. of London, 1880, vol. 63, p. 317. 



212 



ANTERIOR AND DOWNWARD DISLOCATIONS 



The anterior edge of the glenoid fossa is occasionally broken off; the 
acromion and coracoid process have both been found broken, but such 
injury appears to have been purely incidental and should be classed as a 
complication. 

The head of the humerus lies against the edge of the glenoid fossa, 
or further back against the side of the neck of the scapula, and either 
close up against the beak of the coracoid process behind the coraco- 
brachial and the short head of the biceps, or lower down at a distance 
determined by its relations to the subscapularis and by the tension of the 



Fig. 44, 



Fig. 45. 




Subcoracoid dislocation. B, coracoid ; 
C, glenoid fossa. (Malgaigne.) 




Scapula showing new socket found in an 
old unreduced subcoracoid dislocation. 
(Cooper.) 



Fig. 46. 



untorn portion of the capsule. It may lie on the outer side of the cora- 
coid process, "incomplete dislocation," or immediately below it, or it 
may pass entirely to its inner side (intracoracoid dislocation), and it may 
be in outward or inward rotation (Fig. 46) or in any intermediate attitude. 
As has been already said, avulsion of the tuberosities may take the 
place of laceration of the muscles attached to them ; this has been rarely 

noted of the lesser tuberosity, but frequently 
of the greater, and especially of its upper and 
middle facets. Von Thaden, 1 who made a 
study of this feature, found that the upper 
and middle facets were each sometimes torn 
off separately, but the lower one only in 
connection with the other two. The com- 
plication is of importance because of the 
consequent loss of the control of the attached 
muscles over the humerus and the con- 
sequent exposure to recurrence of the 
dislocation (see Chapter III.), and because it opens the way for the 
escape of the long tendon of the biceps from its groove and its inter- 




Subcoracoid dislocation ; to show the 
different degrees of rotation of the 
humerus in different positions. 



1 Von Thaden : Arch, fur klin. Chir., vol. 6, p. 67. 



ANTERIOR AND DOWNWARD DISLOCATIONS, 



213 



position between the humerus and its socket in such a way as to constitute 
a serious obstacle to reduction. In the specimens Von Thaden examined 
he found the tendon thus interposed three times. Korte 1 reported a 
similar case in which the tendon had slipped entirely out of its groove 
and was wound around the outer and posterior side of the head. He 
adds that Stromeyer quotes from Curling a case in which the tendon had 
to be lifted back oyer the head with a spatula before reduction could be 
made. 

Fig. 47. 




Old unreduced dislocation of the right humerus, with interposition of the capsule. At the inner side of 
the head of the humerus is the rent in the capsule through which it passed, and above the rent is the 
greater tuberosity which had been torn off. At the outer side of the coracoid process is an opening in the 
capsule which had been produced by the pressure of the humerus ; through it the glenoid fossa is seen. 

(Hilton.) 

When the tuberosity or a portion of it is thus broken off, the fragment 
lies over or in the glenoid fossa, and the broken surface of the humerus rests 
against the inner surface of the neck of the scapula or engages the edge 
of the fossa. The upper and outer portion of the capsule thus separated 
from the humerus may remain interposed between the head of the humerus 
and its socket and prevent reduction. After reduction of the dislocation 
the tuberosity reunites with the humerus with more or less irregularity 
and deformity. 

Except in connection with fracture of one or the other tuberosity the 
long tendon of the biceps is rarely dislocated, but it is sometimes torn away 
from its insertion or ruptured. 

In some specimens of old unreduced dislocation a vertical groove has 
been found on the articular surface of the head of the humerus which was 
thought to have been caused by prolonged contact with the edge of the 
glenoid fossa. Malgaigne, who took a special interest in the specimens 



Korte : Arch, fur klin. Chir., vol. 27, p. 747. 



214 



SYMPTOMS AND DIAGNOSIS 



Fig. 48. 



as supposed examples of incomplete dislocation, suggested that the groove 
might have been caused at the time the injury was received by the forcible 
impact of one bone against the other. It is interesting to find that this 
suggestion has been recently confirmed by the autopsy in Eve's case men- 
tioned above and by two specimens of recent 
dislocation preserved in the Museum of the 
University of Edinburgh and reported in an 
interesting and valuable paper by Caird j 1 the 
indentation lay wholly or in part along the 
junction of the head and shaft, was from one 
to one and a half inches long, and from one- 
quarter to one-half an inch deep. The inden- 
tations accurately fitted the inner lip of the 
glenoid fossa, and the latter was bruised or 
chipped. The suggestion that the causation 
of fracture of the anatomical neck may be 
referred to the same mechanism seems very 
plausible. 

The large axillary vessels and nerves are 
pressed inward and are rarely injured. Ex- 
amples of the injuries that may be done them 
have been given in Chapter III., and the 
subject has been more freely discussed in 
Chapter VIII. 

The axillary arteiy may be torn across in 
part or completely, probably by being stretched around the head of the 
humerus while the arm is abducted, or its branches, especially the sub- 
scapular and circumflex, ruptured or torn away at their origin. In Korte's 
case, just mentioned, the anterior circumflex was ruptured half an inch 
from its origin. The main nerves also may be compressed or stretched, 
and it is not uncommon to find the circumflex more or less disabled, as 
shown by loss of sensation in the cutaneous region supplied by it. 




Keunited fracture of the greater 
tuberosity of the humerus. (Gurlt.) 



Symptoms and Diagnosis. 

The description of the symptoms will be made simpler by limiting it at 
first to those commonly found in the medium displacements, and subse- 
quently indicating the differences or modifications peculiar to the excep- 
tional grades and conditions. 

The patient sits with his head and trunk inclined toward the injured 
side, and supports the forearm with the other hand. The shoulder is 
flattened on the outer side so that the line of the deltoid runs straight 
down from the acromion and makes a more marked angle with the arm at 
its insertion than is usual. The anterior fold of the axilla lies lower, 
further from the clavicle than its fellow of the opposite side, and its 
creases appear deeper, as if the arm were applied more closely against 
the chest, and the outer part of the subclavicular fossa appears more full. 

The elbow stands a little away from the side and can be easily abducted, 



» Caird: Edinburgh Med. Journ., Feb. 1887. 



SYMPTOMS AND DIAGNOSIS. 
Fig. 49. 



215 




Subcoracoid dislocation of the left shoulder. (From a photograph.) 

but any attempt to bring it nearer the side causes pain and is resisted ; it 
may be in the axillary line, or in front of or behind it. When the elbow 
is flexed at a right angle the forearm is directed forward and inward ; its 

Fig. 50. 




Subcoracoid dislocation (from a photograph.) A points to the acromio-clavicular joint. 



216 SYMPTOMS AND DIAGNOSIS. 

direction can be passively changed to either side, but not freely. The 
hand cannot be brought to the opposite shoulder. 

Voluntary movements of the dislocated joint are declared by the 
patient to be impossible, and pain is complained of in the shoulder, some- 
times extending- down the arm. 

If the axis of the arm, viewed from in front, is prolonged upward by 
the eye it will be seen to pass to the inner side of the glenoid cavity, and 
if the fingers are firmly pressed against the anterior wall of the axilla in 
the line of this prolongation and a little below the coracoid process they 
will encounter the firm resistance of a solid body ; palpation shows this 
body to be globular, and if it can be grasped between the thumb and 
finger, or if the finger can find some projection on its surface, it will be 
found to share in slight movements of rotation communicated to the arm 
by the other hand of the surgeon. 

If now the head of the humerus is sought for by palpation in its 
normal position it will not be found there ; the fingers can be pressed in 
deeply under the acromion from the outer side or behind, and perhaps 
the empty glenoid fossa can be felt ; the outer margin of the acromion 
is prominent and can be easily traced. 

If the elbow be further abducted and the surgeon pass his fingers well 
up into the axilla he can there feel the head of the humerus. 

If the distance be measured from the outer margin of the acromion to 

the external epicondyle of the humerus or the olecranon, it will usually 

be found somewhat greater, perhaps half an inch, 

Fig. 51. on the injured than on the uninjured side, but 

, ^ if successive measurements are taken as the arms 

*?r^- — ~^??C\ are a °ducted the difference will disappear, and 

<...• ~ Tif m com pl ete abduction the distance will be greater 

I l\ on the opposite side. The reason of this is seen 
I II @ ky a glance at Fig. 51. This method of 
I // examination is uncertain in its results and not 

I // very trustworthy at the best. The natural ful- 

/ I ness of the uninjured shoulder may so deflect 

//( the tape as to make the measured distance on 

™ ^T that side equal to that on the other, or the aero- 

Diagram to show the effect of mion on the injured side maybe so depressed 
position upon the apparent t i iat even wnen tne arms are symmetrically 

length of the arm in dislocation -, n n ,, -, n . -, rv , i t i • 

of the shoulder, a, acromion ; placed as regards the body the affected limb is 
b, lower end of humerus more abducted than the other as regards the 

scapula, and the measured distance on that side 
is consequently less. The risk of error is less when both limbs are 
abducted to the height of the shoulder, and in this position the dislocated 
one should be shorter than the other. If the measurement is made with 
the arms dependent, care must be taken to have the tw T o acromions at the 
same height and to have the inferior angles and vertebral borders of the 
tw T o scapulae at the same distance from the spinous processes of the 
vertebrae. 

As in most other dislocations, the capital point in the diagnosis is the 
recognition of the head of the bone and the determination of its relations 
to the socket from which it has escaped. Ordinarily, both of these can 



INTRACORACOID DISLOCATIONS. 217 

be accomplished at the shoulder with ease and certainty, and the exami- 
nation is difficult only when the patient is very fat or the parts much 
swollen. 

As the attitude and fixation of the limb depend mainly upon the ten- 
sion of the untorn portion of the capsule, the limb will be found much 
more freely movable and capable of taking and keeping other attitudes 
when the capsule is freely torn; this fact has an important bearing upon 
the method of reduction, for the "manipulative" methods depend for 
their efficiency upon the prevention of certain movements of the limb 
and the compulsion of others by the untorn portion of the capsule. It is 
in such cases, too, that the diagnostic sign so freely trusted, the inability 
to bring the elbow against the side and to place the hand on the opposite 
shoulder, is lacking or only slightly marked. 

When the displacement of the humerus is less than usual, when its 
head rests upon the edge of the fossa, the " incomplete " dislocation, the 
symptoms are modified to this extent, that the flattening of the shoulder 
and the abduction of the elbow are less, — the elbow may even lie close 
to the body ; but the limb is equally fixed and incapable of being volun- 
tarily moved. It has not infrequently happened that the dislocation has 
been reduced by the manipulations used to make the diagnosis. 

The treatment will be described in connection with that of the fol- 
lowing variety. 

2. Intracoracoid Dislocations (Subclavicular Dislocations). 

To avoid misapprehension I repeat that the term "intracoracoid" was 
applied by Malgaigne to the class of cases which he deemed of most fre- 
quent occurrence, comprising two-thirds of the forty-nine cases of shoulder 
dislocation observed by him at the Hopital St. Louis, those in which the 
head of the humerus is so placed that from one-third to two-thirds or 
three-fourths of its transverse diameter lies to the inner side of the cora- 
coid process. Most of such cases are now habitually spoken of as " sub- 
coracoid," and the terms intracoracoid and subclavicular are restricted 
to those cases in which the bone is displaced still further inward. As 
between " intracoracoid " and "subclavicular " thus employed, I prefer 
the former name because it contains that of the anatomical landmark the 
relations to which form the basis of the classification. 

The injury may be produced by direct violence received upon the 
outer aspect of the shoulder or by hyperabduction of the arm. The 
essential causative feature of the variety, as compared with the sub- 
coracoid, is that the action of the original violence is prolonged, or that 
the secondary cause exaggerates the secondary displacement upward and 
inward. After a primary displacement forward and downward by abduc- 
tion of the limb, anything that forcibly presses or draws the arm inward 
such as pressure inivard against the elbow, or the contraction of the 
deltoid and pectoralis major, may effect this displacement if the head of 
the bone has passed under the subscapulars, or if this muscle has been 
sufficiently torn. The head of the humerus lies against the wall of the 
chest, or rather against the serratus magnus, on one side, and against the 



218 INTRACORACOID DISLOCATIONS. 

costal surface of the neck of the scapula on the other. The subscapularis 
usually is widely torn ; in MacNamara's case, quoted by Malgaigne, 
loc. cit., p. 525, it was untorn, and the head of the humerus had stripped 
it away from the scapula and had risen above its upper border, lying 
against the root .of the coracoid process. No muscle or tendon was torn. 
Pinel dissected an old case in which the head of the humerus was covered 
by the subscapularis although it was situated on the inner side of the 
coracoid process and was distant only one and a half inches from the 
sternal end of the clavicle ; its anatomical neck rested against the under 
surface of the middle of the clavicle. 

The capsule is extensively torn, and the greater tuberosity usually 
broken oif in whole or in part and lying in the glenoid fossa. 

The head of the humerus passes behind the muscles arising from 
the coracoid process (in one recorded case, Roser's, 1 in front of the 
coraco-brachialis and biceps and behind the pectoralis minor) and occa- 
sionally is partly interposed between the contiguous borders of the deltoid 
and pectoralis major, being then subcutaneous. It may lie immediately 
under or a little behind the clavicle, in one case (Meyer) it even pro- 
jected above and behind it, and it has usually been found rotated inward, 
although it seems probable that the free laceration of the capsule, the 
rupture of the subscapularis, and the avulsion of the greater tuberosity 
which usually occur would leave it very movable, and that this observed 
position has been rather the consequence of such mobility which has 
made it possible for the patient to place and keep the limb in the attitude 
of greatest ease, supported across the chest. 

The long tendon of the biceps is broken, or displaced across and 
beyond the fractured surface left by the avulsion of the greater tuberosity. 

The main vessels and nerves lie on the inner and under side of the 
head, and rather behind than directly at the point of contact with the 
wall of the chest. 

Symptoms. — The attitude of the patient and the general appearance 
of the shoulder are the same as in the subcoracoid variety ; the details 
differ mainly in degree, some being less, others more, marked. The flat- 
tening of the shoulder is greater, as is also, in some cases, the fulness of 
the subclavicular fossa, but this fulness is nearer the median line. The 
elbow lies near the side, may be even in contact with it ; the axis of the 
arm prolonged upward in front passes well to the inner side of the cora- 
coid process, and the head can be felt to move when the limb is gently 
rotated. 

The fingers cannot be passed between the head of the humerus and the 
chest-wall, consequently only the shaft and lower portion of the head can 
be felt through the axilla ; but, on the other hand, the lower anterior edge 
of the glenoid fossa and the neck of the scapula can sometimes be felt 
behind the shaft. 

Abduction of the limb is not easy, and is effected by elevation of the 
scapula rather than by movement of the humerus upon it. Differences 
in length, when the arm is dependent, are less constant and marked than 

1 Koser: Arch, fur phys. Heilkunde, 1844, p. 582. The dislocation had lasted 
for seven years, and many attempts had been made to reduce it. 



TREATMENT OF ANTERIOR DISLOCATIONS. 219 

in the preceding variety, but if the arm can be abducted upon the scapula 
the shortening is then greater. 

The dislocation can be transformed into a subcoracoid by traction 
downward and outward. 

Bardenheuer 1 describes in detail tw T o cases coming under his own obser- 
vation in which the dislocated arm was fixed in the position of complete 
horizontal abduction (Fig. 52). In the first case the patient caught at an 




Intracoracoid dislocation, with arm fixed in horizontal abduction (Bardenheuer.) 

object above his head to save himself from a fall forward, and thus caused 
the dislocation by hyperelevation and retroversion of the arm ; in the 
second case the patient fell down a flight of steps, striking upon his side 
with the arm raised. In each case the arm was abducted at a right angle 
with the body and rotated in the direction of supination of the hand ; 
it could be moved forward or downward about 30° and backward 10°, 
but the scapula shared largely in the movements. Rotation of the limb 
was not possible. Measuring from the acromion, the arm was shortened 
an inch or more, and the anterior wall of the axilla was narrowed. The 
head of the humerus passed behind the coraco-brachialis and short head 
of the biceps and lay far to the inner side of the coracoid process under 
the clavicle in the first case, and so far inward in the second case that its 
anatomical neck was directly under the process, and its articular surface 
well to its inner side. Reduction was easily effected in each case with 
the aid of anaesthesia by slight outward rotation and traction. 

Bardenheuer attributes the fixation in this position to the supposed 
anterior situation and narrowness of the rent in the capsule. The integ- 
rity of the outer portion of the capsule would, I think, be sufficient to 
account for the attitude. (See, also, Luxatio erecta. Chapter XVII.) 

Treatment of Anterior Dislocations. (See, also, Chapter VII.) 

Obstacles to the return of the head of the humerus to its socket may 
be created by the tension of portions of the capsule which oppose its 
movement toward the socket, except in certain attitudes of the limb, by 

1 Bardenheuer: Deutsche Chirurgie, Lief. 63, a, p. 317. 



220 TREATMENT OF ANTERIOR DISLOCATIONS 

the approximation of the sides of the rent in the capsule through which 
it has passed, by the interposition of portions of the capsule or of the 
tendon of the biceps, by its engagement behind the edge of the glenoid 
cavity or the coracoid process, and by the contraction or rigidity of the 
muscles and the swelling of the soft parts. Those which are most fre- 
quently concerned are the opposition of the anterior portion of the capsule 
and the contraction of the muscles. 

The portion of the capsule which extends from the base of the coracoid 
process and the outer, or posterior, edge of the glenoid fossa to the 
greater tuberosity and posterior portion of the humerus, including the 
coraco-humeral ligament, usually remains untorn, and is stretched down- 
ward and forward across the glenoid fossa, and, being drawn tight by the 
weight of the elbow, it holds the head of the humerus against the scapula. 
If now the arm is drawn downward, the insertions of the capsule upon 
the scapula and humerus respectively are drawn further apart, the cap- 
sule made more tense, and the two bones pressed more firmly together ; 
but if, on the contrary, the elbow is raised, the capsule is then relaxed, 
and the abducted limb can be drawn outward in the direction of its long 
axis without encountering the previous opposition. 

If the rent in the capsule has been mainly longitudinal, and the head 
has passed entirely through it, traction downward will make its sides 
tense, and thus draw them nearer together, narrow the opening, and 
impede the return of the head ; but if the limb is abducted and rotated 
outward, the anterior edge of the rent will be carried away from the 
other, and the opening made larger. 

If the capsule is so freely torn away from the humerus on the outer 
side that it falls down between it and the glenoid fossa, it cannot be 
lifted out of the way by manipulation of the arm, because its separation 
is so complete that it is no longer aifected by the position given to the 
latter. It may, perhaps, be pushed out of the way by the returning 
bone, but that is a matter of chance rather than of skill. Probably, full 
elevation of the arm followed by traction upward would be most likely to 
accomplish the object under such circumstances. Fortunately, such a 
condition of things is rare. 

Dislocation and interposition of the tendon of the long head of the 
biceps occurs only with avulsion of the greater tuberosity, and not always 
then, for it may, instead, be ruptured. Even when interposed, the 
tendon may be fairly expected to have preserved its relations with the 
lower part of the bicipital groove and sheath, and consequently to be 
still somewhat under control by the humerus. By elevating the arm 
and flexing the elbow it will be relaxed and raised toward the upper part 
of the joint, leaving space below for the head of the bone to pass back 
under it. 

Abduction of the arm and external rotation are, then, the means by 
which the most common obstacles created by the capsule are to be 
avoided. 

As the muscles are elastic and normally somewhat stretched, approxi- 
mation of their ends is immediately followed by a corresponding retrac- 
tion, to overcome which some force is necessary. In addition, there is 
commonly the contraction excited by pain or the fear of pain, which, 



TREATMENT OF ANTERIOR DISLOCATIONS. 221 

unless relieved by anaesthesia, must also be forcibly overcome. Surgeons 
and writers differ widely in their estimate of the importance of this 
obstacle to reduction. Some, arguing from the well-established influence 
of the capsule in determining the position and fixation of the limb, assert 
that the muscles may be disregarded ; others, in my opinion more justly, 
see in them an obstacle of which serious account must be taken, and 
which can prevent the success of the most correct manipulative method. 
It is a matter of common experience that a dislocated bone which remains 
almost absolutely fixed and immovable under forcible traction and manip- 
ulation will slip into place almost at a touch after anaesthesia has relaxed 
the muscles. It is going as much too far on the other side to claim that 
the muscles alone are the obstacle ; their contraction simply holds the 
limb fixed in the position determined by the capsule and opposes move- 
ment in any direction, and when mobility has been restored to the limb 
by anaesthesia or fatigue, then advantage must be taken of it to move 
the bone in the direction determined by its relations to the capsule and 
the neck of the scapula. The habitual facility of reduction and the in- 
frequency of failure at the present time as compared with the past are 
due much more to anaesthesia than to differences in method, for most of 
those methods that are in successful use now have been known and prac- 
tised for centuries. 

A certain anxiety connected with resort to the aid of anaesthesia has 
arisen from the fact that a disproportionate number of the deaths caused 
by chloroform have occurred in the reduction of dislocations (see p. 64), 
but I am not aware that death has ever followed the use of ether under 
such circumstances. There are many reasons why reduction should be 
made, when conveniently practicable, without its aid, but, unless in the 
presence of some important contraindication, I should never hesitate to 
avail myself of the aid of ether in preference to the employment of long- 
continued, forcible, or painful traction, even in recent cases. In those 
of long standing in which adhesions must be broken, the capsule retorn, 
and the shortened muscles elongated, it is indispensable. 

Reduction in recent cases is usually easy, and it has been safely ac- 
complished after the lapse of many weeks and even months. It is 
impossible to fix a period after which reduction by traction should no 
longer be attempted; each case must be judged by itself. Serious, even 
fatal, accidents have followed the attempt so often that the surgeon is 
fully justified in advising abstention on the ground that the risk is too 
great to be taken. Personally, I should prefer in a doubtful case to 
expose the joint by incision and liberate the head of the humerus with 
the knife, rather than seek blindly to break up the adhesions by rotation 
and traction. 

In all the methods in which forcible traction is made upon the arm 
success depends largely upon efficient fixation of the scapula. When 
the traction is made by specially constructed apparatus the counter- 
extension is effected by a ring or crutch arranged to bear against the 
scapula (Fig. 58), but when it is made by the hands of assistants the 
scapula should be fixed by bands as in Fig. 53 or 57. In some cases 
in which only moderate traction is made a simple band about the chest 



222 TREATMENT OF ANTERIOR DISLOCATIONS. 

is sufficient, or the pressure of the surgeon's foot or hand against the 
side of the chest or the top of the acromion. 

Direct reposition. — This method, the use of which can be traced back 
to the time of Avicenna, has been of late especially recommended by 
Richet and Yon - Pitha. It is often successful in recent cases in which 
the displacement and muscular contraction are not great, and especially 
when aided by anaesthesia. The arm, somewhat abducted, is supported 
by the side, and the surgeon placing his fingers in the axilla on the 
under and inner side of the head of the humerus, and his thumbs unon 
the acromion, seeks to press the bone directly into place. Or the posi- 
tion of the hands may be reversed, the thumbs being placed in the 
axilla and the fingers upon the acromion. Or, the patient being seated, 
the surgeon supports the flexed elbow upon his own forearm, gets his 
fingers around the head of the humerus in the axilla, and presses it 
toward the glenoid cavity while he steadies the scapula with the other 
hand. 

Traction downward and outward with coaptation. — This method in 
its many forms differs from the preceding one rather in the amount of 
force employed than in the direction in which it is exerted. Instead of 
exerting only the pressure of the fingers and thumbs to force the head of 
the humerus outward and upward, traction is made upon the arm by the 
surgeon himself or an assistant to draw it outward, and the pressure 
upward is made either by the hands, as in the preceding method, or by 
traction with a band in the axilla. Experience has shown that the 
method is of wider application and more generally successful than the 
more brilliant rotation and fulcrum methods, and the reason is to be 
found in the fact that it more satisfactorily meets all the indications 
arising from the opposition of the capsule and the muscles. It has, 
however, a risk from which the rotation method is free and which must 
be borne in mind especially in elderly patients and in the lower dis- 
placements, that of injury to the bloodvessels by overstretching them. 

In its simplest form, one that is successful in a large proportion of 
cases, the method is practised as follows : The patient is placed upon a 
bed and counter-extension is provided by a band passed around his chest 
and made fast to a support on the sound side. If anaesthesia is used the 
weight of the body is usually sufficient for counter-extension, and this 
band can be dispensed with. Traction is made by an assistant, who 
grasps the arm above the elbow and pulls steadily downward and outward 
at first, and then slowly changes the direction by increasing the abduc- 
tion until the arm is nearly or quite at right angles with the body, while, 
at the same time, he rotates the arm outward. The surgeon, standing 
beside the patient, watches the movement of the head of the humerus, 
and when it has approached the joint he presses it upward into place with 
his fingers or thumb, making counter-pressure on the acromion. 

If anaesthesia is not used, or if more force is used, the scapula must be 
fixed by bands passing over and under the shoulder, as in Fig. 53. Or 
the patient can be laid on his back on the floor, and the surgeon, seated 
beside him places his foot against the side of his chest and draws the arm 
directly outward. Reduction may be effected in this manner without 
the aid of coaptative pressure. 



TEEATMENT OF ANTERIOR DISLOCATIONS. 



223 



It is desirable that the elbow should be kept flexed at a right angle to 
relax the biceps, and also, if the surgeon himself is making traction, to 
enable him to rotate the limb inward when the head has been brought 
close to its socket, since this manoeuvre is sometimes an efficient substitute 
for direct pressure upon the head. 




Reduction by traction ; fixation of scapula. (Cooper 



An ingenious method of developing and applying the necessary force 
was suggested by Dr. J. E. Kelly, 1 who had then employed it in twenty 
cases with only one failure. The patient is placed upon a bed about 
three feet high, close to its edge, and his arm abducted at right angles. 
The surgeon, standing by the side of the bed and facing toward its 
head with his hip against the patient's chest near the axilla, draws the 
patient's arm and forearm across the front of his own pelvis and around 
to the opposite hip, where he holds the wrist firmly. Then placing the 
thumb of the other hand in the axilla and the fingers on the acromion 
he rotates his body outward, keeping the hip well pressed up into the 
axilla and making pressure on the head of the humerus with his thumb. 
The method is capable of developing more force than traction by the 
hands alone, and although it is open to the objection of applying it rather 
blindly and uncertainly, and in that respect is inferior to the others, it 
seems capable of rendering a useful service in some cases. 

An excellent modification in cases in which it is desired to avoid the 
use of an anaesthetic is the substitution of continuous traction by India- 
rubber or a weight and pulley, as used by Legros and Anger, and 
described in Chapter VII., p. 69. 

Another is the so-called " pendel-methode" which occupies a position 
intermediate between this and the following method, hyper-elevation of 
the arm, and in which the weight of the patient's body is used to make 

1 Kelly: Dublin Journ. Med. Sci., Sept. 1882, p. 45. 



224 TREATMENT OF ANTERIOR DISLOCATIONS. 

the traction. The patient is laid upon the floor on the sound side, and 
an assistant, standing upon a stool at his head, grasps the dislocated arm 
and lifts the shoulders from the floor while the surgeon presses the head 
of the bone toward its socket. If a greater weight is needed another 
assistant raises the feet so that the body is wholly off the floor, or presses 
downward against the side of the chest. If a sufficiently robust assistant 
is not at hand, or if the effort is to be prolonged, the suspension should 
be made by means of a rope attached to the w r rist or to the arm above the 
elbow. Bardenheuer says that Simon reduced by this means a disloca- 
tion that had existed for a year and three-quarters. 

Traction upward. — In this method the arm is raised beside the head 
and drawn upon while counter-extension is made by the hand or foot 
upon the top of the shoulder. Duplay, following Malgaigne, speaks of 
it in rather exaggerated terms as the only rational method, because it 
relaxes all the muscles. The difference between it and traction at right 
angles to the body is more apparent than real, because the further eleva- 
tion of the arm is effected by a change in the position of the scapula upon 
the chest, without change in its relations to the humerus. The method, 
which was known to Celsus and practised by Brunus in the thirteenth 
century, was extensively used in England in the last century, but is 
more particularly connected with the name of Mothe in France, and of 
Kluge in Germany. Malgaigne says that he himself reinvented it for the 
fourth or fifth time in 1828 as the result of experiments upon the cadaver. 
It has commonly been combined in practice with some form of the method 
next to be described, the bascule of the French and German authors, that 
in which the head of the bone is pressed outward by placing a fulcrum 
high up in the axilla and then swinging the elbow in toward the body, 
and has also been frequently supplemented with external, followed by 
internal, rotation. 

Fig. 54. 




Eeduction by vertical traction. (Cooper.) 



In its simplest form, as described by Bransby Cooper, and shown in 
Fig. 54, the patient is placed upon his back on the bed or table, and the 
surgeon sitting beside his head draws the dislocated arm upward with 
one hand and fixes the scapula with the other ; the counter-extension 



TREATMENT OF ANTERIOR DISLOCATIONS. 



225 



Fig. 55. 



may be aided by a long bandage or towel passing over the shoulder and 
fixed by both ends to the foot of the bed. After reduction has taken 
place, and while the arm is being lowered, the head of the humerus should 
be held in place by direct pressure upon it. 

Malgaigne's plan, when more force was needed, was to rest the patient 
on the floor, and lift the arm directly upward with both hands, counter- 
extension being made by the weight of the body and aided, if necessary, 
by pressure made upon the acromion by an assistant. If this failed and 
he wished to try more force before resorting to the bascule, he made the 
patient stand beside a door and raised the arm to a vertical position by 
means of a strong band made fast at the wrist or elbow and carried over 
the top of the door ; then the patient was directed to bend his knees until 
the weight of his body should be entirely supported by the dislocated 
arm, and, in addition, the surgeon contributed his own weight by clasping 
his hands over the patient's acromion and kneeling beside him. 

The addition, as proposed by Lacour 1 in 1847, of external and 
internal rotation to the vertical traction, has added to its efficiency, and 
this combination in the form recommended by the late Professor H. H. 
Smith of Philadelphia is very highly praised by Dr. D. Hayes Agnew. 2 

The chief objection to this method is that mentioned in connection with 
the preceding one, that of the risk of injuring the main vessels in the 
axilla by unduly stretching them around 
the head of the humerus, and it is even 
greater here because the elevation, or 
abduction, is made without preliminary 
traction to bring the head nearer the 
socket. 

Another objection is that it is likely 
to increase the laceration of the capsule 
and of the subscapulars and thereby 
promote recurrence of the dislocation. 

Traction ivith leverage. — This method 
differs from that of traction downward 
and outward in the addition, or the sub- 
stitution for direct coaptative pressure 
by the hands, of a leverage movement 
in which the head of the bone is forced 
outward by the adduction of the limb 
over a fulcrum placed in the axilla. 
The fulcrum is usually the closed fist, 
the heel, or the knee. 

When the hand is used traction is 
made outward and downward by an 
assistant, and when the head of the 
bone has been moved sufficiently far the surgeon places his closed fist 
well up in the axilla, and the assistant, still maintaining the traction, 




Seduction by the knee in the axilla 
(Cooper ) 



1 Lacour: Mem. de Chirurgie, 1847, vol. 1, p. 387. 

2 Agnew : Surgery, vol. 2, p. 59. 

15 



226 



TREATMENT OF ANTERIOR DISLOCATIONS. 



swings the arm toward the side (adduction), sometimes combining with 
it moderate inward rotation. 

If the knee is used the surgeon stands behind the seated patient (Fig. 
55) and resting his foot upon the edge of the chair places his knee in the 
axilla ; then grasping the arm above the elbow with one hand and pressing 
upon the acromion with the other he makes traction downward, and then 
pressing the elbow inward he raises his foot upon the toes. The plan is 
clumsier and less efficient than the fist in the axilla, but can be executed 
without the aid of an assistant. 

The heel in the axilla. — (Fig. 56.) This method, generally known as 
Sir Astley Cooper's, but really dating back to the time of Hippocrates, 
was in very general use in England and America until quite recently. 
It is unfortunately responsible for not a few more or less serious injuries 
to the bloodvessels and nerves of the axilla. 



Fig. 56. 




Reduction by the heel in the axilla. (Goopek.; 



The patient is placed upon his back on a bed or sofa and a towel or 
stout bandage made fast to the arm above the elbow. The surgeon, 
facing him, seats himself upon the side of the bed and places the heel of 
one foot, from which the shoe has been removed, well up in the axilla 
ao-ainst the head of the humerus and then makes traction downward upon 
the towel and maintains it until the bone is felt to slip into place. 
Remembering that under these conditions traction upon the humerus is 
directly transmitted to the scapula through the already tense capsule, it 
seems probable that the method owes its efficiency to the action of the 
heel as a wedge, which by being forced in between the thorax and the 
humerus presses the latter directly outward. If the traction is made at 
first in a direction inclined away from the body, and then brought more 
nearly parallel to it, the mechanical effect is the same as when the fist 
is used as above described. 

It may be proper to employ this method if no more force is used than 
can be exerted by the surgeon himself, although accidents have happened 
even under such circumstances, but it is certainly dangerous and improper 
to employ it with the pulleys or assistants, and still more so to substitute 
an iron plug for the heel as recommended and practised by Skey. The 



TREATMENT OF ANTERIOR DISLOCATIONS. 



227 



large vessels and nerves lie upon the inner side of the head of the 
humerus and are exposed to be compressed between it and the heel and 
thus directly bruised or so held fast that they may be overstretched and 
torn as their distal portions are drawn downward in the sliding of the 
soft parts of the arm toward the elbow. 

Forcible extension. — If more forcible traction is needed than can be 
made in the methods already described, resort should be had to the 
pulleys or specially constructed apparatus. The pulleys are made fast to 
the arm above the elbow by a broad leather band buckled tightly around 
it or by a strap or band made fast by several turns of a wet bandage ; it 
is necessary to secure it tightly to the arm, for this does not increase the 
bruising caused by the traction, and if it should slip the soft parts might 
be seriously torn, as in the case quoted from Malgaigne on page 75. 
As a further precaution against slipping the forearm should be bandaged 
and the elbow fixed at a right angle. It is also advisable to interpose a 
dynamometer between the pulleys and the limb to indicate the amount of 
force that is being employed, and a pair of "liberation forceps" to allow 
the traction to be suddenly relaxed and the position of the arm changed. 
(Fig. 57.) 

Fig. 57. 




Keduetion with the pulleys ; 4, dynamometer; G, " liberation forceps." (Duplat.) 



The special instruments, of which the most elaborate and ingenious are 
made in France, are, in the main, modifications of the "adjuster" 
invented by Dr. Jarvis, of Portland, Connecticut. They consist (Fig. 
58) of two bars movable upon each other by a rack and pinion, one of 
which is made fast by a leather bracelet to the lower part of the arm, and 
the other to a ring or crutch that fits against the scapula. A dyna- 
mometer indicates the force exerted, and a catch sets it instantly free at 
will. As the instruments are expensive and the occasions for their use 
are rare, it is seldom practicable to obtain one when wanted. 

Reduction by manipulation. — (Rotation.) It has been already men- 
tioned that rotation of the arm has long been used in connection with the 
various methods of extension to effect reduction, and it also appears that 
from time to time men have sought to reduce, and sometimes with success, 
by moving the limb in various directions without the aid of much trac- 
tion, but it is only within the present century that methods of manipu- 
lation founded upon a correct appreciation of the obstacles and of the 
means by which they may be overcome have been devised and practised 
with intelligence and success. Rotation inward was long employed as the 



228 



TREATMENT OF ANTERIOR DISLOCATIONS. 



final manoeuvre to turn the head of the bone into its socket after it had 
been brought opposite it by traction, and it still constitutes the final step 
in the pure manipulative method. External rotation during traction was 
first employed under the influence of various ideas concerning the part 
taken by the muscles in opposing the return of the bone, or to dislodge 
the head from its position behind the lip of the glenoid fossa ; then, in 
the light of more accurate knowledge of the influence of the untorn 
portion of the capsule, it became the first step in the methods of reduction 
without traction. 

Fig. 58. 




Collin's instrument for reduction of dislocation of the shoulder. 

Of these methods the one that is most highly esteemed and generally 
practised is that recommended by Prof. Kocher, 1 of Bern. The follow- 
ing description is taken from one given at the Surgical Congress in 
London, and published by his pupil Ceppi in the Revue de Chirurgie, 
1882, p. 831. " In the subcoracoid dislocation the posterior portion of 
the capsule and the tendons of the posterior scapular muscles which cover 
and strengthen it are untorn and are stretched over the glenoid fossa. 
The inferior portion of the capsule which forms the lower border cf the 
rent is also very tense. But the tension is greatest at the upper part of 
the capsule, and especially between the long tendon of the biceps and the 
upper border of the subscapularis, there where it is reinforced by the 
fibres of the coraco-humeral ligament. This portion of the capsule is 
twisted in the dislocation, and stretched in the form of a solid cord. If 
now the humerus is rotated externally until the flexed forearm is turned 
directly outward, this cord will be at the same time rotated outward, the 



1 Kocher: Berlin, klin. Wochenschrift, 1870, No. 9, and Volkmann's Sammlung 
klin. Vortrage, No. 83, p. 611. 



TREATMENT OF ANTERIOR DISLOCATIONS. 



229 



posterior part of the capsule will be widely removed from the fossa, and 
the rent in the capsule will gape ; but the head of the humerus will still 
remain solidly fixed against the anterior edge of the glenoid fossa because 
the upper and lower portions of the capsule have not been relaxed by 
this movement. It is only when the elbow is carried forward and raised 
in the sagittal plane, while the arm is still held in external rotation, 
that the upper part of the capsule is seen to relax, and the head of the 
humerus, thanks to the tension of the lower portion which keeps it from 
moving forward, to enter its socket. Rotation inward then completes the 
reduction." 

Fig. 59. 




Kocher's method of reduction by manipulation ; 1st movement, outward rotation. (Ceppi.) 

The method may be formulated in detail as follows (Figs. 59, 60, and 
61). Dislocation of the left shoulder. The patient is seated, and the 

Fig. 60. 




Kocher's method of reduction ; 2d movement, elevation of elbow. (Ceppi.) 



surgeon, kneeling beside him, flexes his elbow at a right angle and presses 
it with his right hand against his side ; then, holding the elbow firmly in 



230 



TREATMENT OF ANTERIOR DISLOCATIONS 



place, he slowly and steadily moves the wrist outward with his left hand 
(external rotation of the humerus), and stops w r hen the resistance becomes 
considerable. The evidence that the movement has accomplished what 
was expected of it is the appearance of greater fulness of the outer deltoid 



Fig. 61. 



If the resistance begins 




Kocher's method of reduction; 3d movement, in- 
ward rotation and lowering of elbow. (Ceppi.) 



promptly, before the fulness has 
appeared, the pressure should be 
steadily maintained for a few mo- 
ments. Then, still maintaining 
the external rotation of the arm 
and the flexion of the elbow, the 
surgeon moves the elbow forward, 
or forward and slightly inward, 
until the arm is horizontal ; during 
this movement the fulness of the 
outer deltoid region becomes more 
marked, and at its termination the 
manoeuvre is completed by rotating 
the arm inward and bringing the 
hand to the opposite shoulder. 
The bone may slip into place dur- 
ing the second movement, elevation 
of the elbow. 

The method as thus described is 
applicable to those cases in which 
the displacement is neither very far 
inward nor low down, in short, to the medium forms of the subcoracoid 
variety; and as it depends for its success upon the resistance of the 
untorn portion of the capsule it will also fail whenever the capsule is very 
extensively torn. It has sometimes been applied with success to the 
more marked inward dislocations by exaggerating the outward rotation 
and maintaining it for about a minute before beginning to elevate the 
elbow ; during this period of waiting it is said a peculiar crackling is 
heard, produced by the outward movement of the head of the humerus. 
I have heard the same crackling during both outward rotation and eleva- 
tion in cases of less displacement and have attributed it to progressive 
laceration of the capsule. Kocher himself modifies the manoeuvre in 
these inward cases by placing the elbow not simply against the side of 
the body in the axillary line, but as far backward and inward as possible, 
or he steadies the head of the humerus and draws it outward by a bandage 
passed under the axilla. 

Konio- 1 modifies it for the lower anterior and subglenoid dislocations 
by making traction in abduction, rotating outward, and then adducting. 
This is practically the same as the method described as traction downward 
and outward and generally known as Lacour's method by manipulation. 

Farabeuf 2 studied Kocher's method experimentally with a view to 
determine the mechanism by which its result was accomplished, and 



1 Konig: Speciel. Chirurgie, 3d ed., vol. iii. p. 40. 

2 Fambeuf: Bull, de la Soc. de la Chir., 1885, p. 395. 



TREATMENT OF ANTERIOR DISLOCATIONS. 281 

reached the conclusion that the efficient agent was the untorn posterior 
portion of the capsule, and that the upper portion, the coraco-humeral 
ligament, had little or nothing to do with it. He showed, experiment- 
ally, that when this latter had been divided and the posterior portion left 
intact the manoeuvre would still effect reduction, but that when the pos- 
terior portion was divided and the upper portion left whole it failed, and 
that then the head of the humerus instead of being moved outward by the 
external rotation simply revolved about the longitudinal axis of the shaft. 
His explanation is clear and intelligible. According to it the approxi- 
mation of the elbow to the side tightens the posterior portion of the 
capsule where it extends between the posterior lip of the glenoid fossa 
and the under and back part of the neck of the humerus ; this prevents 
the posterior surface of the humerus from moving inward when the arm 
is rotated outward, and consequently its attachment to the humerus 
serves as the fixed point or centre about which the bone rolls outward, 
winding itself, as it were, upon the capsule. The elevation and adduc- 
tion of the elbow, turning upon the same fixed point, then throws the 
head backward and further outward, and finally the internal rotation 
unwinds the capsule and leaves everything in place. 

When Prof. Kocher first made his method knoAvn he thought it would 
be useful only in recent cases, but he has since ascertained that it can be 
successfully used in those that have remained unreduced for three or four 
months. Ceppi's paper contains the notes of twenty cases in which 
reduction was effected by this means after a lapse of from three weeks to 
four months. Twelve of them were Kocher 's ; in one the dislocation 
was three weeks old, in two five weeks, in three seven weeks, in four 
three months, and in two four months. He failed in only one case, a 
dislocation of eight weeks' standing in a woman seventy years of age; 
the humerus broke below its middle during the attempt. With such a 
record in its favor the method should certainly receive a trial before 
resort is had to the more dangerous methods of abduction and forcible 
traction. 

Scliinzinger s method, the introduction of which appears to have ante- 
dated Kocher's, w T as in like manner based upon the persistence of the 
posterior portion of the capsule, but differed from Kocher's in the second 
and third steps of the manoeuvre. He rotated the arm outward until 
the hand was as far back as the elbow, and then either pressed the bone 
upward and outward into place by direct pressure, or turned it in by 
slow internal rotation while an assistant made pressure on the inner side 
of its head to prevent it from slipping back into the position from which 
it had been removed by the outward rotation. The method is favorably 
spoken of by several of the later German writers, and is thought to be 
especially useful in rupturing the adhesions of old dislocations without 
the risk of injury to the vessels or nerves. 

Circumduction, sometimes known as Heine's method, in which, after 
fixation of the scapula as for traction, the arm is slowly abducted, raised 
to the side of the head, inclined slightly backward, and then brought 
forward and downward across the face and chest, has been recommended 
and used in old dislocations ; it is undoubtedly efficient in breaking up 



232 TREATMENT OF ANTERIOR DISLOCATIONS. 

the adhesions, but it is a rough, uncertain, and dangerous plan, and 
should be condemned. 

To recapitulate, the treatment of a recent anterior dislocation of average 
displacement may be thus summed up : Kocher's method may first be 
tried ; if that fails, traction downward and outward should be tried, the 
elbow not being raised higher than the shoulder, combined with direct 
pressure upon the head, or followed by adduction over the fist in the 
axilla. If these also fail, the patient should be etherized, and the attempts 
repeated. 

In older dislocations the same plan should be followed, and resort 
should be had to forcible traction only after other measures have failed. 

The signs of a successful reduction are the sound that is usually heard 
when the bone slips into place, the restoration of form and function, and 
the diminution or cessation of pain. The sound is not always heard, 
and, on the other hand, a similar sound may be caused by the rupture of 
adhesions or by the slipping of the bones upon each other. Complete 
restoration of form is the best evidence ; this is to be determined by an 
examination similar to that employed in making the diagnosis of a dis- 
location and by attention to the same signs. The reduction may be 
incomplete because of the interposition of a portion of the capsule, or 
because of the presence of tissues of new formation in the glenoid cavity. 
The incompleteness is shown by the abnormal projection forward of the 
head of the humerus under the acromion. 

After-treatment. — After reduction has been obtained it is highly de- 
sirable that the arm should be immobilized for two or three weeks in a 
position that will favor the speedy repair of the lacerations of the capsule, 
tendons, and muscles ; otherwise the joint may remain in a condition 
that favors recurrence, and the patient may suffer much inconvenience or 
even disability in consequence. As the rent in the capsule is on the 
inner side, and as its edges are separated by external rotation of the 
limb, the head of the humerus should be directed toward the outer side 
(adduction of the elbow) and the arm should be kept rotated inward. These 
two indications are met by binding the limb to the body with the hand 
resting just below the opposite clavicle. Fixation may be made by a 
silicate-of-soda or plaster-of-Paris dressing or even by simple bandages, 
but the most convenient and effective dressing is a strip of adhesive 
plaster arranged as follows : beginning in front at the clavicle it is carried 
over the shoulder and down the back of the arm, then under the elbow 
to the back of the forearm, and along the latter and the back of the 
hand to and over the top of the opposite shoulder. A small pad of 
absorbent cotton or lint should be placed in the axilla and between sur- 
faces of skin that are in contact. If the patient is unruly a second band 
may be placed circularly about the body and lower part of the arm. 
This dressing should be retained for two or three weeks, and the arm 
carried in a sling for a fortnight longer. If passive motion is made, 
abduction and external rotation should be avoided. 

If the greater tuberosity has been broken off in whole or in part and 
widely separated by the retraction of the attached muscles, the indication 
is to favor its reunion by keeping the limb in the position of outward 



TREATMENT OF ANTERIOR DISLOCATIONS. 233 

rotation, an indication that is difficult of accomplishment unless the 
patient stays in bed. Fortunately, such separation of the fragments as 
would make this position desirable is rare ; they are usually kept in 
sufficiently close approximation by the untorn periosteum and liga- 
mentous surroundings. 

For complications, accidents, prognosis, and the treatment of old dis- 
locations, see Chapter XVIII. 



CHAPTEK XYII 



dislocations of the shouldee. — {Continued.) 

DOWNWARD DISLOCATIONS: SUBGLENOID, LUXATIO ERECTA, SUBTRICIP- 
ITAL DISLOCATION. POSTERIOR DISLOCATIONS : SUBACROMIAL, SUB- 
SPINOUS. UPWARD DISLOCATIONS. 



Downward Dislocations. (Subglenoid.) 

Under this title are here included those rare cases in which the head 
of the humerus is displaced directly downward upon the tendon of the 

long head of the triceps, and 
those more frequent ones in 
which it is engaged under the 
lower and inner edge of the gle- 
noid cavity, and rests against 
the flattened upper portion of 
the axillary border of the scapula 
on the inner side of the tendon 
of the triceps. (Fig. 62.) As 
explained in connection with the 
classification given in the pre- 
ceding chapter, the name is here 
restricted to a portion of those 
cases which, are termed subgle- 
noid by most English and Ameri- 
can authors, to those, namely, 
in which the head of the bone 
is low in the axilla. By some 
the term is still further restricted 
in use, and is applied only to the 
first of the two forms above- 
mentioned, those in which the head is displaced directly downward upon 
the tendon of the triceps. Although it is denied by some on theoretical 
grounds that this form can exist, yet it must be admitted not only as 
possible, but as having been actually observed, on the evidence of several 
observers who fully understood the point in dispute. Von Pitha (quoted 
by Bardenheuer) says that he had seen it only in cases in which he had 
the opportunity to examine the patient immediately after the accident, 
and before any movements had been communicated to the limb or attempts 
made to reduce. He believes that the head can be easily displaced from 
its new position, and moved upward and forward, the dislocation being 
thus transformed into a subcoracoid, by involuntary or communicated 




Subglenoid dislocation. 



DOWNWARD DISLOCATIONS OF SHOULDER. 235 

movements of the arm, or even by muscular action. Tillaux 1 observed 
this transformation in a case while he was preparing to make a cast of 
the limb. 

Two subvarieties, representing extreme displacements, and character- 
ized by exceptional symptoms, the luxatio erecta and the subtricipital, 
will be separately described. 

This form of dislocation was studied experimentally by Malle, 2 Groy- 
rand, 3 and Panas. 4 They found that if the scapula w r as fixed, and the 
arm was forcibly elevated, the head of the humerus presented through a 
large rent in the capsule between the subscapulars and the long head of 
the triceps, and that if the arm was then lowered the head would often 
return to its socket, but that if it was twisted outward w T hile being lowered 
the dislocation would persist. The lower border of the subscapulars 
was always found torn, and its untorn portion rested upon the upper 
surface of the head ; and Malle claimed that in order to produce the 
dislocation upon the cadaver it was necessary to divide the portion of the 
capsule between the acromion and the lesser tuberosity. 

The cause, w T ith the single exception of Desault's case, 5 in which the 
injury was said to have been produced by a fall upon the shoulder, has 
always been the forcible elevation of the arm, as in a fall through a 
narrow opening or upon the extended elbow, by a horse throwing up his 
head while being led by the bridle, or as in Goyrand's case of a woman 
who, having fallen to the ground, had her arm dislocated by a passer-by 
who sought to raise her. In one of Tillaux's cases a young girl dislocated 
her shoulder by suddenly raising her arm while playing at raquettes. 

The rent in the capsule in the specimens produced experimentally has 
always been comparatively small, and situated in the lower and inner 
portion between the triceps and the subscapularis, and differs from that 
of the subcoracoid form in not extending so far upward along the anterior 
edge of the glenoid cavity. In a specimen presented by Leroy 6 to the 
Societe Anatomique the lesions were identical with those produced experi- 
mentally. The upper part of the capsule, including the insertion of the 
supra- and infra-spinatus muscles, was torn away from the humerus, from 
the anterior border of the bicipital groove to the tendon of the teres minor, 
a distance of four centimetres ; in the lower portion was the usual rent, 
two and three-quarters inches long, extending from the tendon of the teres 
minor inward and then upward along the anterior border of the glenoid 
cavity. The head of the humerus lay upon the axillary border of the 
scapula one inch below the anterior border of the coracoid process, the 
limb being so far rotated outward that the internal epicondyle was directed 
forward, and the greater tuberosity rested against the anterior lip of the 
axillary border and the adjoining portion of the neck of the scapula. The 
subscapularis was pushed upward and overlapped the head. 



1 Tillaux: Anat. topographique, p. 53G. 

2 Malle: Bull, de l'Acad. de Med., Paris, 1838, vol. 2, p. 941. 
rand : Mem. de la Soc. de Chir., 1847, vol. 1, p. 21. 

\9 



■±)i. 



3 Goyrand : Mem. de la Soc. de Chir., 1847, vol. 1, p. 

4 Panas: Diet, de med. et de chir. pratiques, art. Epaule, p. iu^. 

5 The diagnosis in this case has been questioned. The limb is described as havin 
been very movable, and Goyrand thinks the injury was a fracture. 

6 Leroy : Bull, de la Soc. Anatomique, 1844, p. 102. 



236 



DOWNWARD DISLOCATIONS OF SHOULDER. 



In a case reported by Jossel 1 of subglenoid dislocation caused by a fall 
from the second story of a house, in which death followed on the second 
day in consequence of an associated fracture of the skull, the following 
conditions were found : The subscapular artery was entirely torn across. 
The head of the humerus lay between the partly torn subscapularis 
muscle and the triceps " upon the triangular surface of the lower border 
of the scapula directly below the glenoid fossa." The capsule was 
entirely torn from the humerus, the subscapularis was pushed upward, 
the edge of the glenoid fossa was a little broken at its widest part, and 
the upper and middle facets of the greater tuberosity were broken off, the 
line of fracture running into and opening the bicipital groove. 

In Sedillot's case, quoted by Malgaigne as of this kind, the conditions 
were quite exceptional ; abduction was so marked that the arm was held 
almost horizontal, the head of the humerus was situated half an inch 
below the glenoid fossa, resting against the scapula, but also engaged 
between the latissimus dorsi and teres major in front and the triceps behind. 

Apparently the failure of the head to rise as usual to the level which 
would make the dislocation subcoracoid is due to the resistance of the 
untorn portion of the capsule on the inner side ; and the greater abduction 
of the limb is due to this retention of the head at a lower level, for the 
untorn outer portion prevents the shaft from sinking unless the head 
correspondingly rises. 

Fig. 63. 




Subglenoid dislocation. (From a photograph.) 



Avulsion of the whole or part of the greater tuberosity seems to be 
the rule ; this is equivalent to the division of the upper part of the cap- 

1 Jossel: Deutsche Zeitschrift fur Chirurgie, 1874, vol. 4, p. 124, 






DOWNWARD DISLOCATIONS OF SHOULDER. 237 

sule which was said by Malle to be a necessary preliminary to the 
production upon the cadaver of a dislocation directly downward. 

Symptoms. — The flattening of the outer portion of the shoulder, the 
prominence of the acromion, and the abduction of the elbow are all more 
marked than in the subcoracoid dislocation ; and the axis of the arm 
prolonged by the eye in front passes below and to the inner side of the 
glenoid cavity. Measured in partial abduction from the acromion to the 
elbow, the arm appears longer than its fellow, and this elongation may 
not give place in complete horizontal abduction to as much shortening as 
is found in the subcoracoid form. The head of the humerus can be 
plainly felt in the axilla, and is separated from the coracoid process by 
an interval of from half an inch to an inch. 

The arm is widely abducted, and is usually directed forward and 
rotated outward, and the elbow cannot be brought to the side ; the angle 
made by the flat outline of the deltoid with the axis of the shaft is very 
marked. 

The differential diagnosis from subcoracoid dislocation is made by 
recognition of the position of the head below the glenoid fossa ; the cor- 
roborative symptoms are the more marked flattening of the deltoid, and 
the wider abduction of the elbow. 

Treatment. — Theoretically, the position of the head below the glenoid 
fossa suggests that traction should be made upward and outward, the 
elbow being raised above the shoulder, and this plan is generally recom- 
mended and usually successful. The objection to it is the added risk of 
doing injury to the bloodvessels in the axilla by overstretching them 
around the head of the humerus, as explained in the preceding chapter. 
It is prudent, therefore, that a trial should first be made of the method 
of direct reposition (p. 222), and, that failing, of traction in the direction 
of the arm as found, or with a little more abduction, combined with 
external rotation and followed by adduction while pressure outward and 
upward is made upon the head of the bone, or with the fist in the axilla. 
The reader is referred to the preceding chapter for the details. 

Luxatio erecta. — This striking dislocation first described by Middel- 
dorpf, and his pupil Scharm, 1 who reported the former's two cases, is 
characterized by the marked elevation of the arm beside the head, a 
position from which it cannot be lowered without causing great pain. 
Besides Middeldorpf s two cases I have met with the description or men- 
tion of four others by Busch, 2 Panas, 3 Lange, 4 and Alberti, 5 and a 
reference by Bardenheuer (loc. cit., p. 303), without details, to a case 
reported by Bertin and two cases reported by Meyer. They are in brief 
as follows: 

Busch. A man carrying a heavy sack on his left shoulder down a 
flight of steps fell when near the bottom. He came at once to the 
hospital, with his left arm upright, the forearm resting across the top of 

1 Middeldorpf: Clinique Europeenne, 1859, vol. 2, and Scharm, De nova humeri 
luxationis specie. Dissert. Inaug. Breslau, 1859 ; quoted by Alberti, vide infra. 

2 Busch: Archiv fur. klin. Chir., 1863, vol. 4, p. 30. 

3 Panas : Diet, de Med. et Chir. pratiques, art. Epaule, p. 405. 
* Lange : New York Med. Becord, 1879, vol. 16, p. 400. 

6 Alberti : Deutsche Zeitschrift fur Chir., 1884, vol. 20, p. 475. 



238 DOWNWARD DISLOCATIONS OF SHOULDER. 

the head, and the wrist held firmly in the other hand opposite the right 
ear. He complained of pain extending from the shoulder to the finger- 
tips. The arm was easily lowered nearly to the side, and then presented 
the usual signs of a dislocation, the head of the humerus lying in the 
axilla on the lower border of the glenoid fossa, but after it had been 
lowered the patient asked to be allowed to raise it again to relieve the 
intolerable pain which the position caused. The permission having been 
granted, he threw the arm sharply upward and replaced it in its original 
position. This was repeated several times. When the arm was upright 
the head of the humerus projected markedly in the axilla. Reduction 
was easily made by slight traction upward. 

Panas says only that the patient presented himself with the hand 
resting on top of his head, and sustaining the arm with his other hand. 
The slightest attempt to lower the limb caused sharp pain, and even when 
in bed he rested it upon the pillow beside his head. 

Lange. A man forty-five years old fell forward, grasping with his 
elevated right hand the edge of a barrel as he fell. When seen eight 
hours later, the arm was elevated at an angle of 120° ; its axis, pro- 
longed, would have crossed the junction of the sternum and the third rib. 
Every attempt to lower it caused pain at its middle third, which Dr. 
Lange thought might have been due to tension of the coraco-brachialis. 
The deltoid was relaxed ; the elbow was extended, and the hand supi- 
nated. By bending the body as far as possible toward the injured side 
while the patient was seated the hand could be brought down to the knee. 
The head of the humerus was below and to the inner side of the coracoid 
process and apparently rested against the latter. Redaction was effected 
by increasing the elevation and making traction until the head was 
brought under the coracoid, and then lowering the elbow T and rotating 
inward. 

Alberti. A man thirty-two years old was leading a horse which 
reared and, while descending, struck his elevated arm with his knee. 
The man felt sharp pain in the shoulder, and was unable to lower the 
arm. When seen, the arm was held vertically and inclined slightly for- 
ward and outward, the forearm resting on top of the head ; the hand 
was pronated. Any change of position was guarded against by grasping 
the wrist with the other hand. The acromion was prominent, the glenoid 
fossa easily felt, the deltoid relaxed and thrown into two folds. The head of 
the humerus lay a little behind the axillary line at the level of the middle 
of the outer border of the scapula. The distance from the elbow to the 
acromion was seven centimetres less than on the opposite side when the 
other arm was placed in a similar position. The patient could not 
straighten the elbow, and could only move the fingers a little. He com- 
plained that the hand was numb. He insisted upon taking chloroform ; 
reduction was then easily effected by traction upward and outward. 

The only opportunity for direct examination of the parts was furnished 
in one of Middeldorpf s cases ; the patient's right arm was caught in some 
machinery and he was whirled around, receiving in addition to the dislo- 
cation a wound of the deltoid ; he died of pysemia. The greater tuber- 
osity had been torn off, remaining attached to its three muscles, and the 
acromion was broken. Scharm produced the dislocation five times upon 



DOWNWARD DISLOCATIONS OF SHOULDER. 239 

the cadaver ; in every case the supra- and infra-spinatus muscles were torn 
away, and in two there w T as partial rupture of the subscapulars and 
pectoralis major. The main bloodvessels and nerves were uninjured. My 
only knowledge of Middeldorpfs cases and Scharm's experiments comes 
from the brief mention made of them by Alberti. 

Dr. Lange's case, in which the dislocation was intracoracoid rather 
than subglenoid, differs also from the others in the less complete eleva- 
tion of the arm. Bardenheuer (loc. cit., p. 303) says that in his experi- 
ence, covering about four hundred cases of dislocation of the shoulder, 
he had never encountered a pure luxatio erecta, but he had met with two 
cases in which the arm was abducted beyond a right angle with the body. 
Probably they are the two cases quoted in the preceding chapter as 
unique cases of horizontal abduction. Dr. Lange's case might properly 
be regarded as an exceptional form of intracoracoid dislocation inter- 
mediate between the usual form and the luxatio erecta. 

The mechanism appears to have been forcible and extreme elevation 
of the arm, combined in one case (Alberti's) with a blow upon the arm 
from above downward, and the elevated position after dislocation was 
plainly due to the tension of the anterior soft parts created by the shifting 
of the centre of motion to a point so far below the glenoid cavity. In 
one of Meyer's cases mentioned by Bardenheuer, a woman sixty-two 
years old, it is said that the dislocation occurred during an epileptic fit. 
It is stated also that in one of the cases " paralysis of the brachial plexus " 
persisted after reduction. 

The method of reduction adopted in all the cases was clearly the proper 
one, not only because it succeeded but also because it corresponded to the 
anatomical indications. Traction in the direction assumed by the arm 
drew the head directly back toward its socket by the route along which 
it had escaped. 

Subtricipital dislocation. — Our knowledge of this very rare form is 
limited to a single case observed clinically by Farabeuf, 1 and to subse- 
quent experiments made by him upon the cadaver. As the luxatio 
erecta is produced from a subglenoid by exaggerating the descent of the 
head of the humerus, so the subtricipital is produced from the erecta by 
a consecutive displacement of the head upward and backward, at first 
underneath and then behind and above the long tendon of the triceps, 
a displacement effected by the descent of the elbow in front. 

The case was that of a sailor who injured his shoulder while at sea ; 
five weeks later he landed at Bordeaux, and, attempts made there to 
reduce having failed, he went to Paris. The arm was abducted and 
carried forward, and the head of the humerus rested on the back of the 
scapula two finger-breadths below the angle of the acromion. Reduction 
was not obtained. 

In his experiments upon the cadaver Farabeuf found that after raising 
the arm forcibly and thus tearing the capsule at its lower part he could, 
by a vigorous push or a blow upon the elbow with a mallet, make the 
head of the humerus descend several centimetres below the glenoid 
cavity ; if then the arm was lowered in front the head of the bone moved 

1 Farabeuf : Bull, de la Soc. de Chirurgie, 1879, p. 778, and 1885, p. 390. 



240 DOWNWARD DISLOCATIONS OF SHOULDER. 

backward and became engaged under the tendon, which then held the 
arm abducted and directed forward and more or less rotated inward. 

The circumflex vessels and nerves were bruised and sometimes torn. 
He thought the head of the bone tended always to pass first in front of 
them and then below and behind them as the arm was lowered. The 
capsule and the insertions of the rotator muscles were more or less ex- 
tensively torn. 

Farabeuf 's case is apparently the one mentioned by Poinsot 1 as Sebil- 
leau's and as having been examined by himself in 1881, The limb was 
then in slight abduction and inward rotation, the elbow and fingers 
flexed ; movements at the shoulder were almost completely lost. The 
case is described by Poinsot as one of dislocation backward (sub-acromial 
or subspinous), and no reference is made by him to Farabeuf 's opinion 
concerning it although he is named among the surgeons who had ex- 
amined it. 

Farabeuf maintains that two very similar cases observed by Richet 
and Bottey and named by the former retro -axillary (see posterior dis- 
locations) were really examples of this variety described by him. 

The reason for taking this very exceptional form of dislocation out of 
the group of irregular forms and making of it a class apart is the neces- 
sity for emphasizing the route by which the head of the bone has passed 
to its new position. If in a similar case it should be thought, as was 
thought in Richet's and Bottey's cases, that the tendon of the triceps lay 
below the head and that the dislocation was only an exceptional form of 
the subacromial variety, the attempt to reduce would probably fail, be- 
cause it would be made according to the method suitable to that variety, 
whereas it should be made by first transforming the dislocation into a 
luxatio erecta by raising the elbow to the side of the head, and then 
reducing by direct traction upward. 

Posterior Dislocations. (Subacromial and Subspinous.) 

Dislocations backward are divided into two classes, the subacromial 
and the subspinous, according as the head lies under the projecting outer 
border of the acromion or further back below the spine of the scapula, 
respectively. A variety of the subacromial, to which the name retro- 
axillary has been given, has been recently observed and described by 
Richet and Bottey. 

Although I think this division into two groups is quite generally ac- 
cepted by the profession, yet English and American systematic writers 
upon the subject have, as a rule, refused to adopt it, giving as a reason 
therefor, the fact that the two differ only in an unimportant feature, the 
degree of the displacement, and they apply the term subspinous to all. 
Flower 2 justifies the choice of this name in preference to subacromial on 
the ground that the latter does not express any change from the normal 
situation of the head of the humerus under the acromion. On the other 
hand, it may be fairly urged that as in the great majority of cases the 

1 Poinsot : Translation of Hamilton's Fract. and Dis., p. 8fi7. 

2 Flower: Holmes's System of Surg., Am. ed., vol. i. p. 875. 



POSTERIOR DISLOCATIONS OF SHOULDER. 241 

head is not displaced so far as to the spine of the scapula, the term sub- 
spinous is misleading and improper. I have preferred, in accordance 
with what I believe to be the general practice of the profession, to retain 
both terms with the distinction between them established by Malgaigne. 
Of the two groups the subacromial is much the more frequent, the sub- 
spinous being very rare. The actual difference in their frequency is 
greater than a collation of the reported cases by the titles given them 
would indicate, for not a few of the former have been described as " sub- 
spinous," because the reporters have not discriminated between the two 
varieties but have applied that term to all. 

According to Malgaigne, the earliest recorded mention of this disloca- 
tion was in 1834, and when he wrote, in 1855, he could collect only 34 
cases, of which he had himself observed 3. A very considerable number 
of cases have been recorded since that time (I found 7 in the Index 
Medicus for the years 1878 to 1882), and Panas's opinion that many 
escape recognition, by being mistaken for a sprain or an articular frac- 
ture, seems fairly justified, for not only are the diagnostic symptoms 
sometimes very obscure, but Nelaton said that he had within a short 
period of time seen three cases that had passed unrecognized by surgeons 
of merit. In Malgaigne's statistics 26 were men, and 5 women ; and in 
rather more than a quarter of them the cause was muscular action. Bar- 
denheuer quotes Knox, but without giving the reference, as having seen 
two cases in which the injury was caused by obstetrical manipulations ; 
when seen by him one patient was twenty-one months, the other three 
years old. Possibly these were examples of dislocation due to paralysis 
of the muscles of the shoulder, the paralysis itself being the result of 
obstetrical manipulations. The investigations of Duchenne de Boulogne 
indicate that this is not an infrequent accident, and that the resulting 
dislocation is always subacromial. (See Chapter XVIII.) Bardenheuer 
himself had met with four cases of backward dislocation, in one of which 
both shoulders had been dislocated by a fall forward upon the elbows. 

Experiment upon the cadaver shows that the dislocation can be readily 
produced by forcible internal rotation of the arm, by which the posterior 
portion of the capsule is torn and the passage backward and outward of 
the head is made easy. In some of the cases clinically observed also it is 
plain that this has been the mechanism, and in others it has undoubtedly 
aided. Thus, Piel, who Avrote a thesis on the subject in 1851, saw a 
woman in whom it had been caused by her husband twisting her arm in 
a quarrel. In seven of Malgaigne's cases and in several that have since 
been reported the dislocation occurred during an epileptic fit, presumably 
by internal rotation of the limb. In other cases the cause has been a 
blow upon the front of the shoulder (twice a blow with the fist), pressure 
upon the back of the shoulder while the elbow rested against the ground, 
an attempt to control the patient in convulsions, once the throwing of a 
stone by a boy ten years old, and frequently a fall. The anatomical fea- 
tures of the joint, the results of cadaveric experiment, and such histories 
of cases as are sufficiently complete, indicate that the common mode of 
production is pressure backward and outward upon the head of the 
humerus, either directly or through the elbow, combined with adduction 
of the limb across the front of the chest and internal rotation. Such a 

]6 



242 POSTERIOR DISLOCATIONS OF SHOULDER. 

combination is most frequently found in falls forward in which the weight 
is received upon the elbow, not upon the hand, for in the latter case the 
arm is usually slightly abducted and the force is received squarely against 
the surface of the glenoid fossa instead of obliquely outward. It will be 
remembered that this surface is directed forward and outward, and that 
as the dislocating force must be exerted obliquely to it it must come from 
a point that is in front and more or less to the inner side. One of Mal- 
gaigne's cases is especially interesting from this point of view, as showing 
the conditions of the production almost as clearly as an experiment. A 
woman was trying to take down a box placed high above her head, it 
slipped suddenly into her extended hand, and the dislocation occurred. 
In other words, the force was exerted in a suitable direction upon an arm 
that was elevated, adducted, and rotated inward. 

In a case observed by Tillaux 1 the patient, a man twenty-four years 
old, had his right arm caught in some machinery and was drawn several 
times about a revolving shaft, receiving a subspinous dislocation, and in 
addition having the arm almost completely torn away at its middle by 
being twisted several times upon itself. 

Autopsies have been made in six recent cases in Vhich death was 
caused by associated injuries. In Maisonneuve's case (the specimen is 
pictured in Malgaigne's Atlas, Plate XXII., Figs. 5 and 6) the 
patient fell from a height of thirty feet. The capsule was torn above, 
below, and on its outer side ; the greater tuberosity w T as torn off, broken 
into two pieces, and drawn back below the acromio-clavicular arch by 
the supra- and infra-spinatus muscles to w T hich it remained attached. The 
teres minor and subscapulars were still attached to the humerus ; the 
long tendon of the biceps had been torn out of its groove. The circum- 
flex nerve was uninjured. The head of the humerus lay just below the 
posterior angle of the acromion and was not in contact with either the 
spine or the neck of the scapula, but rested against the posterior edge of 
the glenoid cavity. 

In Laugier's 2 case the subscapulars and supraspinatus were torn from 
their insertions, and the head of the humerus had passed, as in Maison- 
neuve's case also, betw T een the infraspinatus and teres minor and was 
covered only by the deltoid. 

Two cases w r ere reported by Jossel, 3 one a subacromial, the other a sub- 
spinous dislocation. In the first the injury, together with a fracture of 
skull, w 7 as caused by a fall into a cellar. The head of the humerus had 
torn through the teres minor and lay under the acromion ; the limb was 
so far rotated inward that the articular surface looked directly outward. 
The supraspinatus and infraspinatus were uninjured. The capsule showed 
a triangular rent on the outer side just large enough to let the head 
through. The tendon of the subscapulars was still attached to the 
humerus, but under it and close by the tendon of the biceps an irregular, 
movable piece of bone could be felt, the lesser tuberosity, the fracture by 
which it was separated extending into the bicipital groove ; the tubercle 
was split into two pieces, both adherent to the tendon. 

1 Tillaux: Anatomie topographique, p. 586. 

2 Laugier : Gaz. des Hopitaux, 184G, p. 60. 

3 Jo-ssel: Deutsche Zeitschrift fur Chir., 1874, vol. 4, p. 125. 






POSTERIOR DISLOCATIONS OF SHOULDER. 



243 



In the second case the patient fell from the height of two stories, dislo- 
cated the left shoulder, and sustained a compound fracture of the thigh ; 
he died on the fifth day. The head of the humerus (Fig. U4) had torn 



Fro 64. 




Subspinous dislocation of the shoulder. (Jossel. ) 

through the teres minor and lay under the spine of the scapula, separated 
from it by the interposed infraspinatus ; it was directed backward. The 
long head of the triceps was almost entirely torn through, and a piece 
was broken from the axillary border of the scapula just below the glenoid 
fossa. The subscapulars and the adjoining part of the capsule were torn 
away from the humerus, bringing with them the lesser tuberosity, the 
fracture of which was broader than in the preceding case. 

In the remaining two cases the dislocations were subspinous ; in one 
of them, quoted by Malgaigne 1 (loc. cit., p. 5 41), the patient, a man 
sixty-two years old, fell backward, and the wheel of his wagon, which 
carried a load of three and a half tons, passed obliquely across the right 
side of his chest, causing injuries which resulted in his death thirty hours 
later. Several ribs were fractured, as were also the body of the scapula 
and the inner portion of its spine. The deltoid, pectoralis major, teres 
major, and teres minor were torn or crushed, and the capsule was almost 
entirely detached. When the arm was lowered the head of the humerus 
lay below the spine of the scapula in the outermost part of the subspinous 
fossa, the lesser tuberosity corresponding to the edge of the glenoid fossa. 

In the other, reported by Collins, 2 a man sixty years old was knocked 
down and run over, sustaining, in addition to the dislocation of his right 
shoulder, fracture of several ribs ; he died in a few days of pneumonia. 

1 According to Soyez (These de Paris, 1880, No. 179) the case was treated by 
Denonvilliers, who deposited the specimen in the Musee Dupuytren. It is reported 
by Malgaigne as if he had himself observed it; hence has arisen the error of supposing 
thai they were different cases. 

2 Collins: Dublin Journ. Med. Sci., 1879, ii. p. 166. 



244 POSTERIOR DISLOCATIONS OF SHOULDER. 

The capsule was torn on all sides ; the supraspinatus and subscapulars 
were torn away at their insertions, and the long tendon of the biceps 
was detached from the bicipital groove. The head of the humerus lay 
between the teres minor and the infraspinatus " immediately beneath the 
scapular spine;" 

In addition, there is a specimen described by Bouisson, and quoted by 
Malgaigne, the history of which is so incomplete that it must be treated 
as an exception ; the head of the humerus lay under the acromion, and 
the inward rotation was so marked that the articular surface looked 
directly outward, and the greater tuberosity occupied the outer half of 
the glenoid fossa. 

In a case described by Kiister 1 as congenital, but concerning the 
etiology of which some doubt may be felt, a child fourteen months old 
had a backward dislocation of both shoulders ; the elbows were directed 
downward and forward, and both arms were rotated inward, the left one 
very markedly. The patient died in consequence of an operation done 
upon the left shoulder, and at the autopsy the head of each humerus was 
found to be normally developed and resting on the posterior border of 
the abnormally flat and small glenoid fossa. The normal development 
of the head of the humerus, the fact that the departure from the normal 
condition of the glenoid fossa was only such as could be accounted for by 
the changed relations, and the marked internal rotation suggest that the 
dislocations may have been caused by muscular action, or have been the 
consequence of local paralysis due to the pressure of the forceps in delivery 
(see Chapter XVIII.), especially since the report indicates that Kiister 
himself felt there might be a doubt of the supposed congenital character. 

The important complication of fracture of the anatomical neck has been 
reported in two cases, one by Delpech, the other by Malgaigne ; 2 in each 
the cause was a fall upon the shoulder. In Delpech's case the fall was 
due to an apoplexy which soon proved fatal ; the head had passed entirely 
through a large rent in the postero-external part of the capsule, its frac- 
tured surface lay against the subspinous fossa, and its articular surface 
was directed backward and covered by the infraspinatus muscle. The 
muscular attachments to the humerus were all preserved, and the long 
tendon of the biceps was intact. 

Malgaigne's case was not seen by him until eleven months after the 
receipt of the injury ; the head of the humerus could be felt as an immov- 
able, hemispherical body, two inches in diameter, and half an inch below 
the posterior angle of the acromion. The arm was shortened half an 
inch, the elbow slightly abducted and not rotated. The upper end of 
the shaft corresponded to the glenoid cavity. The arm was slightly 
movable ; the head did not share in its movements. 

The results obtained by experiment upon the cadaver are in harmony 
with these post-mortem records. In the subacromial variety the head of 
the humerus is found under the acromion looking backward and inward, 
with its anatomical neck engaged against the posterior edge of the glenoid 
fossa, and the lesser tuberosity lying on the latter. The tendon of the 

1 Kiister: Ein chirurg. Triennium, 1882, p. 256. 

2 Soyez: These de Paris, 1880, No. 179, p. 28. 



POSTERIOR DISLOCATIONS OF SHOULDER. 245 

subscapularis covers the anterior and inner part of the fossa, and is usually 
more or less detached from its insertion upon the humerus, probably by 
direct pressure against the anterior edge of the fossa. The dislocation 
can be transformed into a subspinous one by diminishing the internal 
rotation sufficiently to free the lesser tuberosity, and then forcing the 
humerus backward toward the dorsum of the scapula, tearing the capsule 
more extensively, lacerating the infraspinatus, increasing the separation 
of the subscapularis, and tearing oif also the supraspinatus from its inser- 
tion. The dividing line between the two varieties is necessarily an arbi- 
trary one, and in some cases it must be difficult to determine to which 
variety the case belongs. Malgaigne's definitions are as follows : The 
subacromial is one in which the head of the humerus lies under the pos- 
terior angle of the acromion ; the subspinous, one in which it has been 
displaced behind the angle of the acromion, and lies under the spine of 
the scapula. 

The symptoms in recent cases are not very marked, and the character- 
istic ones may be ma-ked by the swelling. In the subacromial variety 
the shoulder is somewhat broadened, and seems full behind and flattened 
in front. The arm hangs by the side, the elbow usually directed some- 
what forward, and is rotated inward. The coracoid process can be plainly 
felt, and perhaps seen ; the acromion is prominent in front, and the soft 
parts below it can sometimes be sufficiently depressed to allow the glenoid 
fossa to be felt. The absence of the head of the humerus from its socket 
is recognized by pressure made in front, and its presence behind and to 
the outer side is determined by palpation combined with gentle move- 
ments of the limb. In the older cases the subsidence of the inflammatory 
swelling and the atrophy of the deltoid consequent upon disuse make the 
deformity more marked. Voluntary movements are abolished, and com- 
municated movements restricted and painful. Comparative measurements 
have not shown constant or notable differences in length. 

The anteversion and adduction are probably due to the persistence of 
the anterior portion of the capsule, which is noted in most of the autop- 
sies and all the experiments upon the cadaver. 

In the subspinous variety the attitude of the arm in the few reported 
cases has not been always the same ; sometimes the elbow has been held 
close to the trunk and projected forward : in Malgaigne's it was rotated 
inward, but otherwise freely movable, and remained in such position as 
was given to it. In Desclaux's it was held horizontally in front of the 
upper and anterior part of the chest, and as any attempt to lower it 
caused great pain, the patient sought to keep it immovable by placing 
the hand on the top of his head. The local symptoms at the shoulder 
are much the same as those in the subacromial variety; there is the same 
prominence of the coracoid process and acromion, the flattening of the 
front, and the fulness of the back of the shoulder, the absence of the 
head of the humerus from its socket, and its presence behind, in this 
case, of course, further back behind the angle of the acromion, and 
below the spine of the scapula. In two cases (Despres, 1 Rene 2 ) there 

1 Despres: Bull, de la Soc. de Chir., 1879, p. 776. 

2 Rene: Gaz. des Hopitaux, 1882, p. 581. 



246 POSTERIOR DISLOCATIONS OF SHOULDER. 

was an ecchymosis as large as a silver dollar under the skin at the point 
where it covered the head of the humerus; in each case it disappeared 
promptly after reduction and was attributed to the pressure of the bone. 

Richet, in 1882, treated a case which differed widely in one respect 
from both the subacromial and subspinous forms, namely, in that the 
head of the humerus, instead of being in contact with the acromion, lay 
at a distance of two finger-breadths below it, close behind the glenoid 
fossa. He considered it a new variety, representing the first stage in 
the production of the subacromial, and gave it the name of retro-axil- 
lary. The case was published by Bottey, his interne, in the Progres 
Medical, August 5, 1882, and subsequently republished with another 
also observed by Bottey in his graduating thesis. 1 The two cases resem- 
bled each other very closely ; the patients were women, aged seventy- 
eight and seventy-two years, respectively, and the injury was caused in 
each case by a fall upon the shoulder; in one, while walking in the street; 
in the other, from her bed, against a chair. The elbow was directed 
forward and held near the body, and in the second case the patient sup- 
ported the limb with the other hand because of the pain its weight 
caused. The antero-external aspect of the shoulder was flattened, and 
the anterior border of the axilla lowered. The coracoid process and 
acromion were prominent, and the glenoid fossa was empty. The head 
of the humerus could be very distinctly felt, for both patients w T ere thin, 
and there was no swelling, behind the posterior edge of the glenoid fossa 
and slightly separated from it, and distant from the acromion by two 
good finger-breadths. In each case it is stated that the distance measured 
from the acromion to the epicondyle was about half an inch less on the 
injured, than on the uninjured limb, a statement which is inexplicable, 
except on the supposition that the limbs were not symmetrically placed 
when measured, or that their positions were such that' the elbows were 
considerably raised in front. External rotation of the limb was marked. 
Reduction was easily effected by direct impulsion, and both patients 
recovered promptly. 

Farabeuf claims that both these cases were examples of the. variety 
of downward dislocation to which he gave the name of subtricipital, but 
although the symptoms were similar, I think the mode of production, 
and especially the facility of reduction by direct impulsion forward of the 
head make it impossible to accept his opinion. The position of the head 
may be explained by assuming that the rent in the capsule was excep- 
tionally low, and did not extend upward along the posterior border of 
the glenoid fossa. 

The prognosis is favorable as regards the probability of effecting reduc- 
tion (in two or three cases the head has been unexpectedly returned to its 
place by the manipulations employed to make the diagnosis), but it is 
very unfavorable if the dislocation is left unreduced, for then the range 
of motion is usually very slight. In a case reported by Sir Astley 
Cooper, in which the dislocation immediately recurred after every reduc- 
tion, and was finally abandoned; the patient survived seven years, but 

1 Bottey : Deux cas de luxation de l'epaule en arriere et en bas (luxation retro- 
axillaire). These de Paris, 1884, No. 13. 



POSTEKIOR DISLOCATIONS OF SHOULDEK. 247 

remained unable to use or even move the arm to any extent. The ten- 
dency to recurrence was attributed to the separation of the tendon of 
the subscapularis from the humerus, and to the consequent lack of support 
on that side. The same tendency has been noted in other cases. Bar- 
denheuer says it existed in three of his four, and that in two of them 
movements of the joint gave rise to crepitation. In some of the cases 
the full use of the limb has been regained in a very short time after 
reduction, a week or ten days. 

The diagnosis, as has been already said, may be difficult, especially if 
there is much swelling. The injury appears to have been not infre- 
quently mistaken for a sprain or a contusion. The attitude and the 
direction of the axis of the arm, except in the rare subspinous cases, are 
not sufficiently characteristic even to suggest the existence of the injury, 
and unless the examination is systematically made with a view to deter- 
mine the position of the head of the humerus, 'as should be done in all 
cases of injury in this region, the dislocation may be overlooked. If the 
head of the bone can be felt, and its relations to the acromion determined, 
all doubts would be removed. 

Treatment. — Reduction has been easily effected in both recent and old 
cases by a variety of methods. The one that has furnished the largest 
number of successes is direct pressure from behind forward upon the 
head of the humerus with counter-pressure upon the front of the acro- 
mion, usually associated with traction upon the arm, forward or backward, 
or with gentle movements of the limb in various directions. Sedillot 
successfully reduced a dislocation that had existed for a year and fifteen 
days. 

The position and relations of the untorn portion of the capsule indicate 
that the best manipulations would be elevation of the elbow in front 
and toward the median line, combined w r ith inward rotation to relax the 
anterior portion of the capsule, and followed by direct propulsion of 
the head from behind toward its socket, or by traction in the direction 
of the long axis of the arm. Simple external rotation might succeed 
when the articular surface of the head rests against the edge of the 
glenoid cavity, as it sometimes does, for by making the front of the cap- 
sule tense, it would rotate the posterior surface of the bone inward and 
forward, but the success of this manipulation might easily be prevented 
by the increased friction between the two bones ; if the articular surface 
has slipped entirely beyond the edge of the fossa, external rotation 
would only engage it more profoundly behind the neck of the scapula. 

Jobert de Lamballe (quoted by Soyez, loc. cit. , p. 32) accidentally 
transformed one of these into an axillary dislocation while trying to 
reduce it. After making traction to bring the head near the socket he 
carried the limb in a movement of circumduction upward, backward, and 
downward, by which the head was moved to the inner side of the glenoid 
fossa, probably passing below it. Reduction was then made by traction 
outward and forward, followed by a leverage movement over the hand in 
the axilla. 

In a case of subspinous dislocation reported by Dr. J. E. Michael 1 

1 Michael : The Medical News, 1884, p. 621. 



248 UPWARD DISLOCATIONS OF THE SHOULDER. 

reduction made on the fifty-ninth day remained incomplete. The patient 
was a boy, sixteen years old, who had received the injury by a fall from 
a horse ; the head of the humerus lay at the junction of the middle and 
outer thirds of the spine of the scapula, the arm was slightly rotated 
inward, and the hand could be raised only to the nipple. After trying 
elevation and rotation without success, the head was brought by traction so 
nearly into place that the hand could be placed upon the opposite shoulder, 
but the form of the shoulder remained imperfect because of the undue 
prominence of the head of the humerus behind and on the outer side. 
Six months later the deformity persisted and there was considerable 
emaciation of the region ; there was slight mobility, rotation was entirely 
lost, and the hand could be brought to the head only with an effort. 

Upward Dislocations. (Supracoracoid, Supraglenoid.) 

The possibility of the occurrence of this rare form of dislocation, which 
has often been denied, has at last been established by the clinical obser- 
vation of several cases and the post-mortem examination of two. 

The first alleged case was reported by Laugier 1 in 1834 as an incom- 
plete dislocation upward; the second was by Malgaigne. 2 In 1858 
Bourget submitted to the Societe de Chirurgie a paper upon the subject 
containing the accounts of three cases observed by himself, two of which 
he diagnosticated as complete dislocations and one as incomplete, and 
reproducing the cases of Laugier, Malgaigne, and Avrard. Upon this 
paper Morel-Lavallee 3 made an elaborate report, denying the correctness 
of the diagnosis in all the reported cases and attributing the observed 
deformity to a prolonged arthritis, and he supported this opinion by 
quoting the case of Soden, 4 in which the symptoms were the same as in 
Laugier's case, but the autopsy, five months later, showed only an 
arthritis. His arguments appear to me to be sufficiently strong to justify 
the rejection of all the so-called incomplete cases, but the others may, I 
think, be retained in consideration of the results of experiment upon the 
cadaver and of the autopsy in Albert's case, which has been accepted as 
a dislocation although it must be admitted, I think, that in it, too, the 
theory of an old arthritis could be plausibly maintained. The cases on 
record, then, are Malgaigne's, two of Bourget's, and those of Chassaignac, 5 
Holmes, 6 Prescott Hewett (quoted by Holmes), Denonvillier's, 7 Albert, 8 
Busch, 9 Verneuil, 10 and Le Dentu, eleven in all, in one of which (Albert) 
both shoulders were dislocated in the same manner and at the same time. 

The cases that furnished autopsies are Holmes's and Albert's. Holmes's 
patient was a man fifty years old, who had fallen from a height of about 

1 Laugier: Arch. gen. de Med., 1834, vol. 10, p. 65; also in Dictionnaire en 30 
vols., vol. 13, p. 81. 

2 Malgaigne: Kev. medico-chirurg., 1849, vol. 5, p. 30, and Luxations, p. 530. 

3 Morel-Lavallee : Bull, de la Soc. de Ohir., 1858, vol. 8, p. 490. 

4 Soden: Med. Chirurg. Trans., vol. 24, p. 212. 

5 Chassaignac : Bull, de la Soc. de Chir., 1858, vol. 8, p. 472. 

6 Holmes: Med. Chirurg. Trans., 1858, vol. 41, p. 447. 

7 Panas: Diet, de med. et chir. pratiques, art. Epaule, p, 469. 

8 Albert: Chirurgie, 2d ed., 1881, vol. 2, p. 287; also in Wiener med. Blatter, 
1879, p. 453. 

9 Busch: Arch, fur klin. Chir., 187b, vol. 19, p. 100. 

10 Fellier: These de Paris, 1878. 



UPWARD DISLOCATIONS OF THE SHOULDER 



249 



thirty feet, striking upon his head, the left side of his chest, and left 
elbow, and receiving in addition to the dislocation in question a com- 
pound dislocation of the radius and a comminuted fracture of the upper 
portion of the ulna. The head of the humerus formed a large prominence 
in front of the outer part of the clavicle ; movements of the arm gave rise 
to crepitus. No attempt to reduce was made, and the patient died on 
the fifteenth day. 

At the autopsy the head of the humerus was found immediately under 
the skin, having passed through the deltoid near its inner anterior mar- 
gin ; its articular surface was entirely above the glenoid fossa and rested 
upon the stump left by fracture of the coracoid process near its base. 
It was slightly rotated inward. The coracoid process lay on its inner, the 
acromion on its outer side and somewhat posteriorly; the coraco-acromial 
ligament appears to have been in part torn. The subscapulars was in- 
tact, but the muscles attached to the greater tuberosity were torn through, 
except a part of the teres minor. The long tendon of the biceps lay 
below the. head on its outer side: it was still attached to the upper 
margin of the glenoid fossa, but some of its inner fibres had been broken 
away from the muscle. The capsule was torn at its upper and inner part. 

Albert's case was first seen by him several years after the injury was 
received. The patient had dislocated both shoulders by holding on to 
the reins of a pair of runaway horses and being drawn along the ground. 
The deformity was more marked on the left than on the right side, and 
there consisted of a marked rounded prominence on the front and upper 



arcl and 



close by the side, the 



Fig. 65. 



part of the shoulder (Fig. Qd). Both arms hun 
axis being directed obliquely from below upw 
forward in front of the glenoid fossa. The prominence 
formed by the head of the humerus was situated in 
front of the acromion, rising about two centimetres 
above its upper surface, and this elevation could be 
increased by pressing the elbow upward ; the arms 
were so far rotated outward that the transverse diame- 
ter of the lower end of the humerus coincided with the 
transverse axis of the trunk. The outer deltoid region 
was not noticeably flattened, but posteriorly the fibres 
of that muscle were greatly relaxed and the posterior 
edge of the glenoid fossa could be distinctly felt through 
them. The point of the finger could be pressed in be- 
tween the head and the coracoid process. Slight volun- 
tary rotation and movement of the elbow forward and 
back were possible ; very slight passive abduction. The 
left elbow could be flexed onlv to a right angle, further 
flexion being arrested by the triceps. On the right 
side the deformity was the same in character, but less 
in degree, and there was the same limitation of motion, 
made upon the elbow directly upward the movement could be distinctly 
felt to be arrested by bony contact, and this demonstrably occurred 
between the head of the humerus and the clavicle, but if the elbow was 
first carried backward the head could then be pushed up higher. 

At the autopsy the capsule was found attached throughout to the 
anatomical neck of the humerus and adherent also to the upper part of 




Supracoracoid disloca- 
tion. (Albert.) 

If pressure was 



250 



UPWARD DISLOCATION'S OF THE SHOULDER 



its articular surface ; thence it extended without interruption to the mar- 
gin of the glenoid fossa, but its cavity was considerably enlarged. The 
coraco-acromial and coraco-clavicular ligaments were uninjured. The 
upper third of the head of the humerus lay above the level of the coraco- 
acromial ligament, and this overlapping could easily be increased to half 
the head. The glenoid fossa was filled by a thick layer of fibrous tissue. 
In the fuller account given in the Wiener medicinische Blatter, 1879, 
p. 453, quoted by Poinsot, it is said that the long tendon of the biceps 
on the left side was ruptured and its end adherent to the bone in the 
bicipital groove, and that an osteophyte an inch long had grown from the 
base of the coracoid process. 
The other cases are as follows : 

Malgaigne. A man sixty years old was thrown from a wagon, striking 
upon his shoulder while his arm was held close to his side. There was 
much pain and he was unable to move the limb. A " bone-setter " handled 
him roughly and sent him away with his arm in a sling. Two and a 
half months later he consulted Malgaigne. The head of the humerus 
was dislocated upward and forward above the coracoid process, and above 
it reached the under surface of the clavicle, stretching the overlying 
deltoid so that on perforation with a pin the latter proved to be only eight 
millimetres in thickness ; shortening one-fifth of an inch. Traction to 
the extent of more than 400 pounds, combined with pressure upon the 
head downward, outward, and backward and counter-pressure on the 
acromion, failed to effect reduction although it made the head so movable 
that it could be drawn down a finger-breadth below the clavicle. Mal- 
gaigne meditated division of the coraco-acromial ligament, which seemed 
to be the obstacle, but refrained. 

Bourget's cases resembled Ma-lgaigne's closely. 

Busch. (Fig. Q6.) A horse reared and struck the patient, who was 
holding him by the bridle, upon the inner and anterior part of the shoulder 

with his hoof. The head of the humerus was 
displaced upward and forward, the deformity 
closely resembling that in Malgaigne's case ; 
the infraclavicular fossa was deepened, the 
arm hung close by the side, the posterior del- 
toid region was hollowed, the coracoid process 
could not be felt in its place. Reduction 
failed. 

Denonvilliers. A man fell upon his arm, 
but was unable to give the details of the fall. 
The limb hung by the side and was strongly 
rotated outward. Ecchymosis, pain, loss of 
function. The head of the humerus projected 
forward and upward between the coracoid and 
the acromion and in front of the clavicle. 
Oblique traction, combined with a slight move- 
ment of leverage, effected reduction. 

Chassaignac. A man fell from the third 
story of a building. The head of the humerus 
projected directly outward and extended above 



Fig. 66. 




jupracoraccid dislocation ; Basel 
case. (Bardeniieuer.) 



UPWARD DISLOCATIONS OF THE SHOULDER. 251 

the coraco-acromial ligament. Movements of the elbow forward were 
impossible, backward they were more free than normal. The dislocation 
was easily reduced by exaggerated elevation of the arm, but recurred 
when the arm was lowered. 

Hewett. The patient was a middle-aged woman ; the head of the 
humerus lay on the upper and inner side of the glenoid cavity ; there 
was distinct crepitus which ceased after reduction had been made by trac- 
tion with the heel in the axilla. Apparently the patient made a complete 
recovery. 

These accounts are so imperfect that the mode of production cannot be 
determined with any approach to precision except in the cases of Holmes 
and Busch ; in the former the associated injuries at the elbow indicate 
that the blow which produced the dislocation was received there, and that 
the humerus was thereby driven upward and inward, breaking off the 
coracoid process. In Busch's case the blow, by the horse's hoof, was 
received upon the inner and anterior part of the shoulder while the arm 
was elevated ; it seems probable that it struck upon the acromion and 
clavicle and forced them downward past the head of the humerus, and 
that the coracoid process was broken by the pressure of the head of the 
humerus against it, not by the direct impact of the blow. 

The cause in Bourget's first case was quite exceptional: the patient 
was a girl nineteen years old, and the injury was produced during an 
epileptic convulsion by the extension of the arm while the hand was 
pressed against a table. 

Panas's experiments upon the cadaver show that if the arm is strongly 
rotated outward while held close to the body, and then pressed bodily 
upward and forward, the capsule will tear at its upper part and the dislo- 
cation will be produced without fracture of the coracoid process ; at the 
same time the upper portion of the subscapularis is torn. The head of 
the humerus is found to be raised not more than one centimetre above its 
normal position ; the greater tuberosity, which has become posterior by 
the rotation, lies against the under surface of the coraco-acromial liga- 
ment and the tip of the acromion, while the articular surface, looking 
forward and inward, lies partly above and partly below the level of this 
ligament. While the condition thus produced upon the cadaver unques- 
tionably constitutes a dislocation, yet there is nothing in the histories of 
the cases above given to indicate that the same condition existed in them, 
and even supposing it to have been produced in the living it seems highly 
improbable that it would persist long enough to come under the observa- 
tion of the surgeon, for there is nothing to prevent the weight of the limb 
and the tension of the untorn portion of the subscapularis from drawing 
the bone back into place. 

Fracture of the coracoid process certainly existed in Holmes's case 
and possibly also in Hewett's and Busch's. Busch was led by his experi- 
ments to think that this fracture was necessary to the production of the 
dislocation, an opinion that cannot stand in the face of the other reported 
cases although in them the integrity of the process is not always specifi- 
cally stated. He knew only of Malgaigne's case and his own, and his 
experimental reproductions of the dislocation were effected by first making 



252 UPWAKD DISLOCATIONS OF THE SHOULDEK. 

a subcoracoid dislocation and then a secondary displacement upward, a 
method in which fracture of the coracoid is essential to success. 

The symptoms consist in the absence of the head of the humerus from 
the glenoid cavity and its presence in the interval between the coracoid 
process and the acromion, close in front of the clavicle and usually rising 
above its level. The coracoid process can be felt with difficulty, if at all. 
The limb hangs by the side, perhaps slightly abducted, and rotated out- 
ward ; its axis is directed from below upward and forward, passing in 
front of the normal position of the head. Usually voluntary movements 
are almost or quite impossible, and passive movements greatly restricted, 
and this restriction exists in old as well as in recent cases. 

In three cases seen while the injury was recent, Denonvilliers, Chas- 
saignac, and Hewett, reduction was easily effected by traction in two and 
by elevation of the elbow in one, but the dislocation recurred in the 
latter ; Verneuil reduced on the thirty-sixth day by traction aided by 
anaesthesia. In Holmes's case the associated injuries were so severe that 
reduction, for which the aid of chloroform was thought to be necessary, 
was not attempted. Malgaigne, Bourget, and Busch failed, the duration 
of the dislocation at the time of the attempt being two and a half, six, 
and five months respectively. The details of Bourget's second case are 
not given, and the result in Le Dentu's I do not know. In Albert's 
the dislocation had existed for many years, and no mention is made of 
any attempt to reduce. 



CHAPTEE XVIII. 

dislocations of the shoulder. — {Continued.) 

ASSOCIATED INJURIES AND COMPLICATIONS. ACCIDENTS. PROGNOSIS 

AND AFTER-TREATMENT. HABITUAL DISLOCATIONS. CONGENITAL 

AND PATHOLOGICAL DISLOCATIONS. 

The complications which may coexist with a dislocation have been 
described in Chapter III., and will therefore be treated but briefly here, 
and mainly with the view of adding some details to the account already 
given. In like manner the accidents which may be caused by attempts 
to reduce a dislocation have been described in Chapter VIII. , some of 
them, especially those relating to the bloodvessels, in detail. 

The injuries which are more or less frequently associated with dislo- 
cations of the shoulder, but which are without such special bearing upon 
the prognosis or treatment as would make them actual complications, 
have been mentioned in connection with the different forms of dislocation 
in the preceding chapters. The most important are the lacerations of 
the different muscles and tendons or their equivalent avulsion from the 
humerus with more or less of the tuberosities to which they are attached. 

Laceration of the subscapularis is the rule in most dislocations, and 
avulsion of the lesser tuberosity to which it is attached is very rarely 
substituted for it, apparently only in some of the backward dislocations. 
The extent of the laceration of the muscle can only be inferred from the 
extent and direction of the displacement, and it is believed to be without 
important influence upon the completeness of the repair and the sub- 
sequent security of the joint. The position of adduction and inward 
rotation in which the limb is habitually kept during the period of conva- 
lescence favors the repair of the muscle, and since the rupture is usually 
incomplete the torn portions do not widely retract. 

With the muscles attached to the greater tuberosity it is somewhat 
different. The muscles themselves are rarely torn, although in the in- 
frequent backward dislocations the lower portion of the infraspinatus is 
usually lacerated, but the upper and middle facets of the greater tube- 
rosity to which the supra- and infra-spinatus muscles are attached are 
frequently broken off and more or less retracted under the acromion, or 
the tendons are torn away from them and retracted. The importance of 
this associated injury, through its effect upon the subsequent usefulness 
and security of the joint, is often great ; not only may the poAver of 
voluntary external rotation be diminished thereby, but the consequent 
loss of support on the outer side of the joint favors recurrence of anterior 
dislocation, and the great lengthening of the upper portion of the capsule 
and the enlargement of its cavity which are effected by the retraction of 
the supraspinatus and the establishment of free communication between 



254 DISLOCATIONS OF THE SHOULDER. 

the joint and the subacromial bursa make the joint much less secure, and 
this condition is thought to be the cause of the marked tendency to 
recurrence observed after many anterior dislocations (see Chapter III.). 
Similarly the avulsion or rupture of the subscapularis in backward dis- 
locations is responsible for the tendency to recurrence that has been so 
frequently noted in them. 

The tendon of the long head of the biceps appears habitually to escape 
rupture ; its sheath may be opened by the avulsion of either tuberosity, 
and then it may slip over the corresponding portion of the head, and, 
becoming engaged between the latter and the glenoid cavity, thus con- 
stitute a serious obstacle to reduction. When ruptured, its end is re- 
tracted into its sheath in the bicipital groove and there becomes united 
with the bone. 

Fracture of the greater tuberosity appears to be not often capable of 
demonstration ; at least it has often been found post-mortem when it had 
not been recognized during life, although the proper explanation of the 
failure to recognize it may be that it was not sought for. If the fragment 
is retained in contact with the humerus by the untorn periosteum crepi- 
tation may perhaps be obtained by manipulation ; and when the fragment 
is widely withdrawn it may perhaps be felt under the acromion, or its 
absence may be recognized by the change in the shape of the corre- 
sponding part of the humerus, or the fracture may be indicated by excep- 
tional symptoms accompanying the dislocation, such as greater mobility 
of the limb or the absence of fixed abduction of the elbow. Bardenheuer 
attaches much diagnostic importance to the presence of an extensive 
ecchymosis on the arm as indicative of fracture of the greater tuberosity. 

Fracture of the lesser tuberosity is much less frequent. To the three 
cases mentioned in the chapter on fractures of the tuberosities of the 
humerus (Fractures, p. 363), may be added the two reported by Jossel 
and quoted in the preceding chapter in the section on posterior disloca- 
tions (p. 242). 

The treatment of associated fracture of the greater tuberosity does not 
hold out much promise. All that can be done in case of separation is to 
place the limb in a position that diminishes or annuls the separation 
between the fragment and the surface from which it has been torn, but 
unfortunately this position (abduction and external rotation) is not only 
one that cannot well be maintained except in bed, but it also is one that 
opposes the prompt and complete repair of the rent in the inner and 
lower part of the capsule wmich is usually associated with the fracture. 
Possibly the two opposing indications could be harmonized by first 
keeping the limb abducted and rotated outward for a week or more until 
the fragment shall have probably formed a sufficiently firm union with 
the humerus to allow the limb to be adducted and rotated inward without 
renewing the separation. Probably the occasions are very rare when the 
separation is so complete that satisfactory union will not take place even 
if the arm is kept in the usual attitude of adduction and internal rotation. 

The serious complication of fracture of the anatomical or surgical 
neck of the humerus has been described with illustrative cases in Frac- 
tures, p. 372. The complication has recently been made the subject of 



ASSOCIATED INJURIES AND COMPLICATIONS. 255 

a thesis by Oger, 1 who has collected in it a large number of recorded 
cases. 

The fracture may occupy the anatomical or the surgical neck, or may 
extend through the tuberosities, or may be extensively comminuted. Of 
68 cases collected by Thamhayn 2 the fracture in 14 was of the anatomical 
neck ; in 2 of these reduction was effected. The displacement in the 
great majority of cases is forward and inward, the head lying under or 
on the inner side of the coracoid process ; in a few T cases it has been back- 
ward under the acromion. The upper fragment may, in addition, 
undergo rotation that will widely separate its broken surface from that 
of the shaft. Illustrative cases of the rare form in which the head, after 
fracture of the anatomical neck, has undergone complete reversal while 
remaining within the cavity of the joint have been quoted in Chapter III., 
and in Fractures, p. 360. The upper end of the lower fragment is 
usually drawn upward toward the glenoid fossa, overlapping the upper 
fragment on the outer side, and it may unite in this position by fibrous 
or bony union with the other fragment, or with the scapula. 

Even when the upper fragment is completely detached from its peri- 
osteal and tendinous connections it may preserve its vitality and estab- 
lish new T vascular connections ; in rare instances it has become necrotic 
and has been eliminated after prolonged suppuration ; usually it atrophies 
and undergoes those interstitial changes which are so frequently seen in 
disused bones. 

The diagnosis appears, in some cases, to have presented serious diffi- 
culties, because the fracture removed some of the most characteristic 
symptoms of the dislocation, such as the fixation and attitude of the limb, 
and the indication of the position of the head of the bone that is furnished 
by the direction of its long axis. In general terms, it may be said that 
when the dislocation of the head has been recognized the coexistence of 
a fracture may be determined by the mobility of the limb, by its short- 
ening, and by the greater extent of the ecchymosis, in case the indepen- 
dent mobility of the head and shaft cannot be recognized and crepitation 
is not perceived. When the signs of fracture are apparent the coexist- 
ence of a dislocation can only be recognized by determining the absence 
of the head from its socket, and this may be made very difficult by the 
swelling of the soft parts. The importance of the mobility of the limb 
as an indication of a coexistent fracture when the presence of a dislocation 
has been recognized, of the possibility of bringing the elbow into contact 
with the side of the body, has been strongly insisted upon by one of the 
most skilful and experienced of the younger French surgeons, M. Berger, 3 
but, I think, without giving full weight to the fact that the same mobility 
may be the consequence of extensive laceration of the capsule without 
fracture. The two positive signs, which the surgeon should spare no 
pains to recognize, are the absence of the head of the humerus from its 
socket, which proves the dislocation, and its failure to share its move- 
ments communicated to the shaft, which proves the fracture. The recog- 

1 Os;er : Luxations scapulo-humerales compliquees de fracture. Those de Pari?, 
1884, No. 361. 

2 Thamhavn : Schmidt's Jahrbuch, 1868, vol. 140, p. 194 

3 France Medicale, 1884, Nos. 132-134. 



256 DISLOCATIONS OF THE SHOULDER. 

nition of fracture of the anatomical neck can hardly fail to be very 
difficult. 

The treatment also presents grave difficulties because the existence of 
the fracture deprives the surgeon of that control over the movements of 
the head of the bone which, in a simple dislocation, can be exerted through 
its shaft. Reduction in a recent case can be effected, if at all, only by 
direct impulsion of the head back into place. This should always be 
attempted, and with the aid of angesthesia. It may be aided by gentle 
traction in a suitable direction upon the shaft, for the periosteal connection 
may be sufficient to make it practicable thereby to bring the upper frag- 
ment into a more favorable position. If the attempt succeeds, the joint 
must be carefully watched in order to detect a recurrence of the disloca- 
tion, for if the upper fragment is small it may be pushed out of place by 
the lower fragment as the latter is drawn upward by the contraction of 
the deltoid. This late displacement after fracture of the anatomical neck 
has been observed and pointed out by Mr. Hutchinson (see Fraetures, p. 
359), and, of course, it is still more likely to occur w T hen there is a rent 
in the capsule through w T hich the head can escape. It is best guarded 
against by continuous traction downward to oppose the action of the 
deltoid. 

In case of failure to effect reduction while the injury is recent, the 
surgeon has the choice between seeking to obtain consolidation, either 
with a view to effect reduction afterward, or to have the limb in the best 
obtainable position, or establishing a false joint at the point of fracture. 
Illustrative examples of the different plans have been given in Fractures, 
p. 382. In addition to the two cases there quoted, von Langenbeck's 
and Warren's, I know of only one other in which the attempt to reduce 
after consolidation of the fracture was successful, while the failures have 
been comparatively numerous, and the consequences of the attempt some- 
times serious or fatal. The conditions appear to be far less favorable for 
reduction even than in simple dislocations that have remained unreduced 
for any length of time, and the reason therefor is undoubtedly to be 
found in the altered condition of the soft parts adjoining the fracture 
w T hich have become matted together in their new relations. Fortunately 
the records show that in many of the cases left unreduced the limb became 
fairly useful. 

The establishment of a nearthrosis between the upper end of the lower 
fragment and the glenoid cavity has been followed by excellent functional 
results in some cases. The smaller the upper fragment the more likely 
is this plan to be successful, for not only does the subsequent usefulness 
of the arm depend largely on the preservation of the attachments of the 
scapular muscles, but also, if the fracture is through the surgical neck, 
the fragments are likely to remain in such relations to each other, and 
to be so connected by bands of periosteum that close, perhaps bony, union 
will take place between them and defeat the attempt to create a new 
joint. If the attempt is made the upper end of the lower fragment should 
be kept pressed outward and upward ; Volkmann recommends for this 
purpose a pad in the axilla, with adduction of the elbow to the side, and 
its support by bandages passed under it and over the shoulder. The 
arm should be kept perfectly quiet for a fortnight, and the inflammatory 



ASSOCIATED INJURIES AND COMPLICATIONS. 257 

reaction further opposed, if necessary, by the application of cold, and 
then, when the danger of provoking suppuration by passive motion has 
passed, the limb may be gently moved daily, and the range of motion 
increased as experience shows it prudent and safe to do so. 

Operations with the knife for the removal of obstacles to reduction in 
fresh cases are, in my opinion, to be condemned. Surgeons relying upon 
the security afforded by antiseptic treatment have sometimes recommended 
this plan of making reduction, but I am convinced that no antiseptics 
can make it safe to lay open a large joint that is in communication with 
a recent fracture and so extensively lacerated soft parts as are found about 
a dislocation. For the same reason I would reject primary excision of 
the upper fragment ; it is, in my opinion, far more safe to wait until the 
inflammatory and reparative processes have ceased : the surgeon may 
then make his incision and remove the upper fragment, if it seems de- 
sirable, with a reasonable expectation that his wound will not suppurate, 
or that if it does the suppuration will be slight and the patient's life will 
not be put in danger. 

Fracture of the shaft associated with dislocation of the shoulder has 
also been observed several times. It is a much less serious complication 
than fracture of either the anatomical or the surgical neck, because the 
greater length of the upper fragment makes it easier to effect reduction. 

Fracture of the coracoid process has been observed in connection with 
dislocation of the humerus, not only in the two cases of supracoracoid 
dislocation mentioned above (Holmes and Busch), but also in dislocation 
forward. One case reported by Manzini, and also seen and quoted by 
Malgaigne, 1 is interesting also because of the extent of the associated 
fractures and the preservation of the vitality of the completely separated 
head. The patient survived the injury two months. The autopsy 
showed a comminuted fracture that separated the head at the anatomical 
neck and included the surgical neck, the coracoid process broken in 
several pieces, and the head greatly hypertrophied, covered with irregular 
bony growths, and firmly attached to the surrounding parts by cellular 
tissue of new formation. 

Fracture of the acromion has also been occasionally observed. Kron- 
lein's unique case in which a blow received upon the top of the shoulder 
first broke the acromion and then dislocated the humerus into the axilla 
has already been mentioned. Bardenheuer (loc. cit., p. 343) briefly 
mentions a case in which a man was run over by a wagon and received 
a fracture of the acromion, a fracture of the surgical neck of the humerus, 
and a dislocation of the humerus into the axilla. 

Fracture of the glenoid fossa. — Probably the chipping of the edge 
of the glenoid fossa is not infrequent in dislocation, and passes unrecog- 
nized because of the lack of symptoms. Fracture of a large portion has 
been occasionally observed, both clinically and after death, and is of great 
importance in favoring recurrence of the dislocation. Malgaigne repre- 
sents in his Atlas (plate 22, Fig. 4) a case in which the anterior third of 
the fossa was broken off and had been displaced backward and become 
united with the neck of the scapula ; the symptoms in the case were that 

1 Malgaigne: Luxations, p. 547. 
17 



258 DISLOCATIONS OF THE SHOULDER. 

the shoulder was less full and rounded than normal, and that the head of 
the humerus, while still in relation with the anterior part of the acromion, 
projected a few lines in front of the inner border .of the coracoid process. 
Bardenheuer made the diagnosis of fracture of the posterior border of the 
fossa in three cases of backward dislocation, on the ground that he could 
easily move the head of the humerus backward and forward by pressure, 
each movement being accompanied by crepitation in the posterior part of 
the joint. 

The special indication for treatment is to prevent recurrence of the 
dislocation by fixation of the limb and pressure upon the head from the 
side on which the fracture has taken place. 

Nerves. — Injury to the nerves, except of a slight and transitory 
character, is rare, and in most of the cases reported as such the injury 
has been inflicted during reduction. I know of only two cases in which 
the injury has been demonstrated by post-mortem examination, Hilton's 1 
and Parise's ; 2 and even in these there was only a partial laceration of 
the circumflex nerve in the former, and in the latter rupture at different 
levels of the fibres composing it, only recognizable on minute dissection ; 
the nerve trunk was extensively infiltrated with blood ; the dislocation 
was subglenoid, and the nerve was tightly stretched around the head of 
the humerus. In all the others the evidence is clinical ; and in estimating 
this evidence it must be borne in mind that partial paralysis of the arm 
may be caused by a fall in which neither the shoulder-joint nor the main 
nerve trunks have been directly involved. 

It is far from uncommon to find in unreduced dislocations that the 
sensibility of the skin over most of the deltoid region, which is supplied 
by the circumflex nerve, is diminished or lost, and that in others after 
reduction the deltoid is paralyzed. This paralysis of the deltoid is 
thought frequently to be the result of direct bruising of the muscle by the 
violence that caused the dislocation, but that explanation does not satis- 
factorily account also for the loss of sensibility in the skin, and we must, 
in such cases, assume that the trunk of the circumflex has been stretched 
in the dislocation. 

In many of the reported cases it cannot be determined whether the 
injury to the nerve was caused by the dislocation or by the manoeuvres 
made to effect reduction ; in others it is clearly due to the dislocation. 
Illustrative examples have been quoted in Chapter III. 

The cause of the paralysis, when it involves more than the circumflex 
nerve, is very obscure. It has been attributed to compression of the 
main trunks in the axilla, but this explanation is not satisfactorily sup- 
ported by post-mortem examination or experiment, and the fact already 
mentioned that similar symptoms may follow blows that neither produce 
a dislocation nor directly involve the nerves adds to the difficulty. 
Nelaton sought to explain it by supposing a compression of the nerves 
between the clavicle and the first rib, and some cases have been reported 
which indicate that this explanation may, sometimes at least, be the 
correct one. On the other hand, the prompt disappearance of the symp- 

1 Hilton : Guy's Hosp. Kep., 1847, vol. v. p. 93. 

2 Parise : G-az. Medicale de Paris, 1863, p. 210. 



ASSOCIATED INJURIES AND COMPLICATIONS. 259 

toms in some cases after reduction clearly points to pressure by the head 
of the humerus upon the nerves as the cause. 

The paralysis may appear immediately or may develop gradually 
during the first two or three clays, and it may be complete or partial. In 
some cases (see Chapter III.) it has been followed by serious changes in 
the appearance and nutrition of the limb, presumably the effect of an 
ascending neuritis. In one case Bardenheuer (loc. cit., p. 335) demon- 
strated the existence of neuritis and perineuritis by exposing the nerves, 
and worked a gradual cure by stretching their trunks. 

Whatever doubt may exist as to the direct cause of the paralysis, the 
first step in the treatment is to reduce the dislocation ; after that has been 
accomplished, or even if it should fail, electricity should be persistently 
employed. Some cases respond promptly to treatment, the contractility 
of the muscle sometimes reappearing after even the single application of 
a blister, while others, after weeks or months of treatment, will show no 
improvement. So long as the muscle reacts to electrical stimulation the 
prognosis is good. 

Bloodvessels. — The complication of serious injury to the bloodvessels 
in the neighborhood of the joint is not frequent, and in the recorded 
cases there is often a doubt whether the injury was caused by the dislo- 
cation or by the attempt to reduce it. The subject has been discussed 
in detail in Chapters III. and VIII. 

An interesting variety of the lesion is one noted by Parise in the case 
quoted in the preceding section (p. 258) : the inner and middle coats of 
the posterior circumflex artery were torn through along the upper half of 
their junction with the axillary artery, the outer coat at the correspond- 
ing point and all three coats of the lower half of the junction remaining 
untprn. No extravasation of blood took place during the three and a 
half hours the patient survived after the accident. What results would 
have followed if the patient had permanently survived is an interesting 
subject of speculation. Certainly the conditions were favorable for the 
formation of an aneurism. 

Chest. — A unique case reported by Prochaska, in which the head of 
the humerus was forced into the chest between the second and third ribs 
is quoted in Chapter III., p. 38. 

Compound dislocations are rare; the wound in the skin is commonly 
in the axilla, sometimes further inward through the pectoralis major, 
sometimes behind the joint. It is a very serious complication, although 
there is reason to hope that a larger proportion of successes will be 
obtained in the future under the improved methods of treating wounds 
than was possible in the past. The essentials of such treatment are 
immobilization of the joint, drainage, and surgical cleanliness ; excision 
of the head of the humerus may also be required under certain circum- 
stances, such as difficulty of reduction or retention, coincident fracture, 
uncleanliness of the wound, and imperfect drainage of the joint. Several 
striking cases of rapid, uneventful recovery have been reported, but I 
must again repeat that the laceration and bruising of the soft parts, the 
extravasation of blood, in short, the traumatism, create a condition which 
is radically different from that created by an incision made by the surgeon 
through healthy, uninjured soft parts into a joint that is not already 



260 DISLOCATIONS OF THE SHOULDER. 

acutely inflamed, and that a repetition of the successes so commonly ob- 
tained under these latter circumstances is not to be expected under the 
former. I believe the more prudent course is to assume that the wound 
will probably suppurate, and to modify the dressing accordingly, by pro- 
viding abundantly for drainage, by not closing the skin wound except, 
perhaps, in part, and by packing with iodoform gauze for at least twenty- 
four hours. The last-named precaution, which has proved so valuable in 
other irregular and oozing wounds, seems to be equally indicated here ; 
its chief advantage is that it provides a prompt and ready means of escape 
for the blood and exudations, and at the same time does not prevent the 
wound from being closed a day or two later with sutures and then healing 
as rapidly and kindly as if it were entirely fresh. I must add, however, 
that I have never had to treat a compound dislocation of the shoulder. 

Simultaneous dislocation of both shoulders is deemed a rare occur- 
rence ; possibly it is more frequent than is generally supposed, for I found 
five cases mentioned in the Index Medicus for the years 1880 to 1885. 
It is of interest only as a curiosity, for the combination does not seriously 
affect the prognosis or treatment. The causes in the five cases referred 
to were as follows. In one 1 the patient was seized in the street by two 
thieves who drew his arms upward, outward, and backward, producing 
subcoracoid dislocations ; both joints had previously been repeatedly dis- 
located. In the second 2 the patient, while standing on a platform, was 
caught under one arm by a chain and thrown to the ground. In the 
third 3 a woman, eighty-six years old, fell out of bed, receiving an intra- 
coracoid and a subcoracoid dislocation. In the fourth 4 a girl, twenty-one 
years old, was knocked down by a falling Avail ; and in the fifth 5 the 
injuries occurred during an epileptic convulsion. All of them were 
anterior dislocations. Mention has been made in the preceding chapter 
of Bardenheuer's case in which both shoulders were dislocated backward 
by a fall forward upon the elbows, and of Krister's case of double back- 
ward dislocation which he reported as congenital. 

Associated dislocation of the elbow has been twice reported. Morel- 
Lavallee's 6 patient was injured in a railway accident; the head of the 
humerus was driven out through the skin of the outer part of the shoulder 
and projected so far that the elbow was in contact with the axilla; the 
elbow also was dislocated. 

Moxhay's 7 patient was a man, fifty-six years old, who was struck on 
the back of the arm by the handle of a wrench and sustained a backward 
dislocation of both bones of the forearm and a subcoracoid dislocation of 
the shoulder ; the latter injury was not discovered by the surgeon until 
the seventh week after the accident ; it was then successfully reduced. 

Injuries caused by attempts made to reduce dislocations have been 
described in Chapter VIII. 

1 G. E. Moore : N. Y. Medical Kecord, 1880, vol. 18, p. 96. 

2 CasMe: British Med. Journ,, 1881, ii. p. 854. 

3 Giiterbock: Berlin, klin. Wochenschrift, 1885, vol. 12, p. 346.. 
* Zinker : Idem, p. 418. 

5 Frankel: Verhandl. Berlin, med. Gesellschaft, 1885, xiii. p. 150. 

6 Morel-Lavallee : Bull, de la Soc. de Chir., 1853, vol. 8, p. 490. 

7 Moxhay: Lancet, 1882, ii. p. 938. 



PROGNOSIS AND AFTER-TREATMENT. 261 



Prognosis and After-treatment. 

Since our knowledge of the pathology of dislocations and of the com- 
mon obstacles to reduction has become so much more accurate and 
complete, and especially since the introduction of the use of ether and 
chloroform, failure to reduce a recent dislocation of the shoulder has 
become very exceptional. Bardenheuer says that of 400 such cases 
treated by him within ten years he has not failed in any, and only once 
has he had any difficulty. The prognosis, therefore, so far as the reduc- 
tion of recent dislocations is concerned, is eminently favorable. It is 
also more favorable for the older dislocations, up to four or five months, 
than it formerly was, and for the same reasons ; and at the same time 
such cases have become more uncommon, for, as a rule, they are now 
only those in which the dislocation has been overlooked or not treated. 

The prognosis is also favorable as regards the complete restoration of 
the functions and security of the joint, but this restoration may be 
delayed or prevented by inflammation or partial ankylosis of the joint or 
by paralysis of some of the muscles, and the security may be seriously 
diminished by partial failure of repair or by permanent changes in the 
joint surfaces. 

The after-treatment is directed to the retention of the head of the bone 
in its place until such time as the repair of the injuries to the capsule 
and periarticular tissues is sufficiently advanced, and to the prevention or 
cure of inflammation and ankylosis. 

It occasionally, though very rarely, happens that the dislocation is 
reproduced within a few minutes of the reduction, without such movement 
of the arm (abduction or elevation of the elbow) as would explain it, and 
it is then presumably due to muscular contraction, perhaps aided by the 
interposition of a clot or of a portion of the capsule. It suggests the 
desirability of immediately and securely fixing the arm to the side of 
the body before the patient is allowed to move after reduction has been 
made, and of inspecting the limb shortly afterward. 

The traumatism is always followed by some inflammatory reaction and 
the evidences of a more or less prolonged arthritis, but it seldom happens 
that this is sufficiently violent to cause apprehension or require other 
treatment than immobilization of the limb. The severer cases are those 
in which the limb has been too early or too freely used. The fear that 
prolonged immobilization of a joint would lead to its permanent stiffness 
is, or has been, too prevalent and has led to much untimely passive or 
active motion of joints that have been injured, and this in turn, by keep- 
ing up the irritation, has increased the stiffness which it was designed to 
diminish. As has been well pointed out by several writers, notably by 
Verneuil, 1 the best antiphlogistic for an inflamed joint is absolute rest, 
and the stiffness which is found afterward is the result of the inflammation, 
not of the immobility, and may confidently be expected to diminish or 
disappear if permanent changes have not taken place in the constituent 
parts of the joint. By this it is not meant that the position of the joint 
may not be changed from time to time, or even that passive motion 

1 Yerneuil : Bull, de la Soc de Chirurgie, 1879. 



262 DISLOCATIONS OF THE SHOULDER. 

within the limits set by pain is not allowable in cases in which the arthritis 
is slight. On the contrary, such measures may not only be permissible 
but may even be advantageous in suitable cases in shortening the term of 
convalescence, and may possibly prevent the formation of adhesions that 
would permanently limit the range of motion. But the formation of 
such adhesions is exceptional, and, moreover, there is every reason to 
believe they can subsequently be broken or lengthened if they should form. 
The retraction of the capsule, the loss of its pliability, to which some 
writers attach so much importance, is, except in the case of prolonged 
inflammation and in some highly arthritic individuals, only temporary 
and will ordinarily yield to the natural daily use of the limb. 

If the inflammation is more severe or if it has been prolonged by 
imprudent use of the limb the immobilization should be supplemented by 
traction downward. Bardenheuer (loc. cit., p. 412) highly recommends in 
addition that the upper end of the humerus should be kept pressed out- 
ward and backward by a pad in the axilla attached to a weight above 
and behind the shoulder. This necessitates the recumbent posture. 

If marked rigidity persists after the subsidence of the inflammation 
and does not yield to ordinary use of the limb the adhesions should be 
broken up by the surgeon by freely moving the limb in all directions with 
the aid of anaesthesia. See also Chapter VII., p. 72. 

Paralysis of the deltoid causes the loss of voluntary abduction of the 
arm, and if prolonged leads to permanent shortening of the under and 
inner portion of the capsule with consequent limitation of passive abduc- 
tion. It may also be followed by the sinking of the humerus downward 
through lack of the support normally given by the deltoid, and by con- 
sequent loss of security in the joint. Usually these paralyses get well 
spontaneously or under treatment by blisters or electricity, but sometimes 
they are permanent. 

Habitual dislocation, by which is meant a more or less marked 
tendency to the reproduction of the dislocation by slight causes, such as 
the abduction of the arm, is not infrequent and may constitute a serious 
disability ; it is most frequently observed after anterior dislocations, but 
appears to be relatively more common after the posterior ones. 

This tendency has generally been attributed, though without anatomical 
proof, to laxity of the capsule, itself the consequence of imperfect repair of 
the rent made in it at the time of the dislocation, but the recent researches 
of Jossel 1 show, for the forward dislocation, that the enlargement of the 
capsule observed in such cases takes place at its upper portion in conse- 
quence of the rupture or avulsion of the tendons of the supra- and infra- 
spinatus muscles, which involves the rupture of the capsule at the same 
level and the creation of a free communication between its cavity and 
that of the subcoracoid bursa (see Chapter III., p. 41). He found this 
condition at the autopsies of five joints which had been subject to habitual 
dislocation during life and in four other specimens found in the course of 
an examination made with this object of all bodies received in the dis- 
secting-room during two successive winters. 

Not only is the cavity of the joint enlarged and the upper portion 

1 Jossel : Deutsche Zeitschrift fur Chir., 1880, vol. 18, p. 167. 






HABITUAL DISLOCATIONS. 



263 



of the capsule greatly relaxed by this lesion, but the connection of the 
two muscles above named with the humerus is permanently lost, and this 
latter is probably the efficient factor in diminishing the security of the 
joint and favoring recurrence of the dislocation. Abnormal laxity of 
the upper portion of the capsule would not favor dislocation forward 
when the arm is in the attitude (abduction) which experience has shown 
to be most favorable to its occurrence, for even the normal capsule is 
then relaxed, and dislocation takes place by rupture on the opposite side. 
But the loss of the control normally exerted by the external rotators 
allows the bone to move bodily to the inner (anterior) side, at the same 
time that it diminishes the steadiness and vigor with w T hich the head of 
the humerus is pressed against the glenoid fossa. 

The relative frequency of recurrence of the subacromial dislocation, 
and the fact that rupture or avulsion of the tendon of the subscapularis is 
common in this form confirm this view. The head of the humerus is 
held against the shallow glenoid fossa by the muscles that pass on either 
side from the dorsal and costal surfaces of the scapula to the greater 
and lesser tuberosities, respectively, and the destruction of these connec- 
tions on either side leaves the head loose and free to move to the opposite 
side. 

Lobker 1 presented at the Fifteenth Congress of German Surgeons a 
specimen obtained, post-mortem, from a case of habitual dislocation, 
which showed changes in the head and glenoid fossa which were thought 
to be the effect of the frequent recurrence, and another specimen obtained 
by Vogt by excision in a similar case, and showing the same changes in 
the head of the humerus. The head in each case was normal only on 
its inner anterior half; the other half had lost its roundness, and showed 
a depression one centimetre deep and two centimetres wide, extending 
from top to bottom, and separated from the normal inner half by a sharp 
prominent border. The surface w T as covered throughout by cartilage, 
and the depression was evidently not the result of a fracture with loss of 
substance. The tuberosities and bicipital groove were intact; the long 
tendon of the biceps was torn from its insertion, and had become 
adherent in its groove. There were evidences of the avulsion of the 
muscles from the greater tuberosity. The outer portion of the glenoid 
fossa was normal, and separated by a sharp vertical border from the large 
inner portion which was angularly deflected backward. Both portions 
were covered w T ith cartilage, and showed no sign of fracture. The head 
and fossa fitted together in such a way that the inner-half of the head 
articulated with the inner-half of the fossa, and the sharp edge of the 
latter occupied the depression in the former. 

He refers to the fact that specimens obtained by excision by Cramer, 
Krister, and von Volkmann, showed similar losses of substance in the 
head of the humerus, and accepts Jossel's explanation as correct for a 
large number of cases of habitual dislocation. The changes shown by 
his own, and the other similar specimens, he attributes to the frequent 
recurrence or to a persistent subluxation by which the head is made to 



Lobker: Beilage zum Centralblatt fur Chir., 1886, 



90. 



264 DISLOCATIONS OF THE SHOULDER. 

rest against the inner border of the fossa, instead of squarely against its 
face. 

The symptoms presented by Looker's case during life are not given, 
but it does not seem possible that they could have been, at least, at the 
last, such as are found in habitual dislocation, for that is characterized 
by complete restoration of form in the intervals between the recurrences, 
while in this case the subluxation must have been persistent. 

Three cases of habitual dislocation in which the head of the humerus 
was excised are referred to by Lobker as showing similar losses of sub- 
stance in the humerus, but a reference to the original reports shows that 
in all three the loss w r as thought to be the result of a fracture, although 
in the discussion on one of them (Krister's), Riedinger expressed the 
opinion that it was due to absorption. As the cases illustrate also the 
method of treatment by excision, I quote them briefly. 

Cramer's 1 patient w T as a woman thirty years old, who dislocated her 
shoulder forward and inward during an epileptic fit, and again in another 
two months later; the arm was then immobilized for several months, and 
a special dressing was w r orn most of the time afterward, especially at the 
menstrual periods, when the attacks of epilepsy were most likely to occur, 
but nevertheless the dislocation recurred nineteen times w r ithin five years, 
each time during a fit; reduction was sometimes easy, sometimes quite 
difficult, and the patient was eager to be relieved of the annoyance and 
the dread. The head was excised through an anterior incision, and the 
patient made a good recovery. The functional result was fairly satis- 
factory and was still improving two years after the operation. 

The articular surface of the head of the humerus showed a shallow 
loss of substance on its outer side four centimetres long, two broad, and 
about three-fourths of a centimetre in depth at the centre (Fig. 67), and 

there was found a small body of irregular 
Fig. 67. shape, one centimetre in its greatest diameter, 

with a smooth surface, and attached by a long, 
thin pedicle to the posterior margin of the 
glenoid fossa. It was composed of bone cov- 
ered by fibrous tissue with bits of cartilage 
between them in places, and w r as thought to 
be a fragment broken from the head. 

Volkmann's 2 patient was a man thirty years 
old, Avho dislocated his shoulder during an 
epileptic fit ; three years afterward it was again 
r dislocated by slight external violence, and in 
Horizontal section of the head of the following three years it was again dislo- 
the humerus in Cramer's case of cated eight times at shorter and shorter inter- 

habitual dislocation. A loss of sub- ^ ^ i ^ glightest causes# When taken 
stance. B, greater tuberosity. C, . ii«iiTi • i i l -i 

lesser tuberosity. mto the hospital the dislocation could be easily 

produced and reduced, and the patient earn- 
estly desired an operation, because no bandage was sufficient to keep 
the bone in place. Singularly enough, after the patient had been 

1 Cramer: Berlin, klin. Wochenschrift, 1882, p. 21. 

2 Volkmann, reported by Popke : Znr Kasuistik und Therapie der inveterirten 
und habituellen Schulterluxationen, Halle, 1882. Abstract in Ctlblatt fur Chir., 
1883, p. 28. 




HABITUAL DISLOCATIONS. 265 

anaesthetized for the operation, the dislocation could not he reproduced ; 
at the most, the head could only be so far subluxated as to rest on the 
anterior edge of the glenoid fossa. The excision was done through an 
anterior incision. 

The posterior third of the head showed a smooth surface not covered 
by cartilage, which had been " undoubtedly"' produced by the breaking 
off of a wedge-shaped piece. No such fragment could be found in the 
cavity, and it was thought to have been absorbed. The glenoid articular 
fossa was altered in shape, having become narrower below than above. 
The capsule was torn away from the inner and lower margin of the 
glenoid fossa, thus creating an opening which communicated with the 
subscapular bursa. On the thickened edge of this opening was attached, 
by a sort of pedicle, a piece of cartilage-covered bone, " which was 
evidently the remains of a fragment broken from the edge of the glenoid 
fossa." (This, if so, would be a sufficient explanation of the recurrence.) 
The patient recovered from the operation, and subsequently reported by 
letter that the condition of his arm was much more satisfactory than 
before the operation. 

Kiister's 1 patient was a young man whose dislocation was caused by 
the fall of a box upon his shoulder ; it recurred on the fourteenth day 
and again five times during the following three or four months. Kiister 
made an exploratory incision in the axilla, thinking he might find an 
unhealed rent in the capsule ; no rent was found, but, on the contrary, 
the capsule was exceptionally thick and firm. The incision was extended 
into the joint, and the head of the humerus was excised. It showed a 
large loss of substance, but no fragment was found in the cavity. At 
the time of the report, seven weeks after the operation, the patient could 
already make all voluntary movements of the limb except elevation. 

These changes in the bones are essentially the same as those described 
in cases of chronic, non-suppurative inflammation, in some of which it is 
evident that the process originated in a dislocation. (See Gurlt; Path.- 
Anat. der G-elenkkrankheiten, pp. 250-267, and especially Curling's case, 
280, also described in the Med.-Chirurg. Transactions, 1837, vol. 20, p. 
336, as a partial dislocation forward.) It seems not improbable that the 
series of observed changes may be started by an ordinary dislocation, that 
is, by one that is not distinguished by any exceptional lesion such as partial 
fracture of the head or of the edge of the glenoid cavity ; this is followed 
by a non-suppurative arthritis which so modifies the capsule and the 
shape of the surfaces that a recurrence of the dislocation is made easy. 
The pedunculated bodies composed of bone and cartilage, sometimes 
found in the joint and thought to have been broken from the head of the 
humerus or the edge of the glenoid fossa, may be of new formation. 

The frequency of recurrence varies greatly in the different cases : in 
some the intervals are long, in others the dislocation is produced every 
time the elbow is raised, and in some the bone can be voluntarily thrown 
out of place by the contraction of the muscles. 

1 Kiister : Eleventh Congress of German Surgeons. Beilage zum Centralblatt 
fdr Chir., 1882, p. 73. 



266 DISLOCATIONS OF THE SHOULDER. 

Ordinarily reduction is very easy, and the patient learns to effect it 
himself; in others it is at times difficult. 

The treatment by injections of iodine and by excision of a portion of 
the capsule on the inner side has been mentioned in Chapter VII., p. 73. 
In view of the above explanation of the cause of the tendency it is not 
entirely clear how the removal of a piece of the inner portion of the cap- 
sule in anterior dislocations should do any good, unless, in consequence of 
the frequent recurrence, that side also should have become relaxed and 
elongated. Excision of the head of the humerus has been resorted to in 
at least four cases, and the reported results in three of them were good. 
I should think the disability would have to be great to justify so radical 
a measure, one which may in itself be so disabling. 

Another class of cases in which the tendency to recurrence is the 
result not of a primary traumatic dislocation but of pathological changes 
in the joint or of paralysis of the muscles will be considered in a sub- 
sequent section. 

If the dislocation remains permanently unreduced the periarticular 
muscles become wasted and the deformity of the region is thereby in- 
creased. The head forms a new socket for itself, but its availability for 
motion is slight, and the use of the limb is confined as a rule to the 
"underhand " movements. In some cases the compensatory mobility of 
the scapula is such that the hand can be raised to the head, and in some 
a degree of usefulness has been exceptionally obtained that is far in 
excess of what is usual. Thus, Prochaska's patient, the head of whose 
humerus was lodged in the chest after having passed between the second 
and third ribs, earned his living for many years as a woodchopper. 

Treatment of old dislocations that cannot be reduced by manipulation 
and forcible traction. — The urgent desire of patients to be relieved of 
their disability or of the pain caused by the persistence of the displace- 
ment has occasionally led surgeons to resort to cutting operations in the 
hope of restoring the bone to its place or improving its position, or to 
excise the head. The attempts made by Desault and Dupuytren at the 
thumb found few imitators there or at other joints until quite recently, 
since improved methods of treating wounds have diminished the attendant 
risks ; but in the meantime subcutaneous division of the muscles or 
tendons was occasionally employed with apparent success, and of late 
subcutaneous division of the capsule or of tissues of new formation about 
the displaced bone has been recommended or employed. Others have ' 
sought to improve the position of the limb or to create a false joint by 
subcutaneous fracture or division with the saw, and others again have 
excised the head of the humerus. It is not always easy to determine 
from the histories of the cases the measure of success or improvement, 
for in some the report ends with the operation, and in others although 
the result is called a success the description leaves the reader in doubt 
as to the completeness of the reduction or as to the improvement in 
function. With our more accurate knowledge of the changes in the con- 
dition of the glenoid fossa and in its relations with the capsule that follow 
the prolonged absence of the head of the humerus from it, we may well 
doubt the completeness of any reputed reduction obtained by subcutaneous 
measures or feel justified in believing that the benefit attributed to the 



TREATMENT. 267 

use of the tenotome was a delusion, and that the really efficient agents 
were the manipulation and the traction. In this criticism I do not in- 
clude those tenotomies or divisions of muscles which in the earlier days 
took the place now filled so much more easily and safely by anaesthetics. 
It is addressed mainly to a method employed by Polaillon 1 in 1882, and 
subsequently used by some and highly recommended by others on his 
authority. 

Subcutaneous section. — Polaillon's patient had an intracoracoid dislo- 
cation, produced during an epileptic fit, that had existed for four months. 
An attempt to reduce with the pulleys, aided by chloroform, failed, but 
brought the head of the humerus nearer its socket and directly under the 
coracoid process. Eleven days later the patient was again chloroformed, 
a blunt-pointed tenotome introduced through a small cut made through 
the skin and muscle a finger-breadth below the tip of the acromion, and 
carried horizontally inward between the deltoid and the point of the 
humerus, its edge turned backward, and then withdrawn so as to divide 
the tissues lying upon the bone ; the point of the knife was then carried 
through the same incision to the back of the humerus, and a similar cut 
made along the outer aspect of the head. Two days later the traction 
was renewed under chloroform, and the dislocation reduced. A week 
later, the bone having meanwhile shown a constant tendency to become 
displaced forward and inward, a tourniquet was applied about the shoulder 
to keep it in place. A month later the patient was able to raise his hand 
to his mouth and to pull it behind his head, and "the movements were 
daily gaining in extent." 

It is not so uncommon for a second or third attempt to reduce by trac- 
tion to succeed after the first has failed, that the success in this case can 
be unhesitatingly attributed to the subcutaneous division, and, further- 
more, it seems doubtful whether an incision made from the outer side in 
this manner could divide anything that offered any serious obstacle to the 
return of the bone. 

The additional cases, in which this method was successfully employed 
by Polaillon, are briefly mentioned in a thesis by Bardon-Lacroze. 2 One 
patient was sixty-two years old, and had an intracoracoid dislocation of 
four weeks' standing. After an unsuccessful attempt to reduce by trac- 
tion, the subcutaneous section w T as made, and two days later the attempt 
was renewed, and reduction was obtained when the traction reached 160 
kilogrammes. The other patient was seventy-six years old, very feeble, 
and partly paralyzed, with a subclavicular dislocation of seven weeks' 
standing. The section was made without any previous attempt to reduce ; 
the following day reduction was easily obtained with a traction of 70 to 
80 kilogrammes. It cannot be said that these cases are any more demon- 
strative of the value of the section than the first one was. 

On the other hand, the same writer quotes from a private communica- 
tion made to him by Moliere, of Lyons, as follows : " I believe the method 
of subcutaneous section of the fibrous bands is an excellent one. In the 

1 Polaillon : Bull, de la Soc. de Cliir. 1882, p. 129. 

2 Bardon-Lacroze : Des sections sous-cutanees comme moyen de reduction des 
luxations anciennes du coude et de l'epaule. These de Paris, 1882, No. 209. 



268 DISLOCATIONS OF THE SHOULDER. 

case in which I used it it gave me a perfect and unexpected result ; I 
had previously made traction with an enormous force without result. " 

An open arthrotomy, by which the surgeon is enabled to see and 
remove the obstacles to reduction, is not only more likely to be successful 
than subcutaneous division, but, if carefully clone when the tissues have 
not been lacerated and inflamed by recent forcible attempts to reduce by 
traction and manipulation, is also, in my opinion, not more dangerous. 
How serious the consequences may be, if the operation (arthrotomy) is 
undertaken in recent cases or after forcible attempts to reduce, is shown 
by the result in Polaillon's 1 case of dislocation of the femur thus treated ; 
it ended promptly in death by acute septicaemia, although conducted 
under antiseptic precautions. It has of late been quite frequently 
employed in the dislocation of other joints, especially the elbow, thumb, 
and astragalus, but only rarely at the shoulder, only three times, the 
cases of Albert, Thiersch, and Burkhardt, although in one or two others 
it was undertaken and then completed as a resection. 2 

Albert's 3 case was a subcoracoid dislocation, the duration of which is 
not stated. An incision, eight centimetres long, was made in front between 
the humerus and glenoid fossa, the sides of the wound held widely apart, 
and all tense bands divided ; then rotatory movements were made by 
which the head was moved in a "really gorgeous" manner toward its 
socket, but, just as it was about to spring in, the bone broke at the sur- 
gical neck. Two sharp hooks were then engaged in the head, and it was 
drawn into place, and the fragments were united by a suture. " The 
result was a pseudarthrosis at the seat of fracture, but the patient was 
bettered by the operation ; the movements were much more free, and he 
was content." 

Of Thiersch's case I have only the brief mention by Albert that the 
operation was an arthrotomy, and failed to effect reduction. 

Burkhardt's 4 patient was a woman forty-eight years old ; the disloca- 
tion was downward and forward, and had lasted seven months. Several 
unsuccessful attempts had been made to reduce it. A longitudinal 
incision, 13 centimetres long, and beginning midway between the acro- 
mion and coracoid, was made and carried down to the glenoid fossa, 
which was found to be covered with thick fibrous tissue ; this was dis- 
sected away, and a very strong band which held the head in its abnormal 
position was divided, and the " tendons on the inner side were subperi- 
osteally detached. The reduction, however, could not be effected without 
tearing off the greater tuberosity." A drainage tube was placed in an 
opening made at the back of the shoulder, and the limb was immobilized 
as for fracture of the clavicle. The operation lasted an hour and a half, 
recovery followed, without accident or suppuration, in four weeks. Three 

1 Polaillon : Bull, de la Soc. de Chir., 1883, p. 101. 

2 Dr. Garmany, of New York, has recently (Oct. 1887) employed it with success 
in a iresh case. 

3 Albert: Chirurgie, 1881, 2d ed., vol. 2, 319. ISTicoladoni quotes Kosenmayer, 
Wiener med. Blatter, 1883, p. 17, as saying that Albert did this operation twice in 
1874 for old dislocations of the shoulder ; but this seems to have been an error, the 
second operation being on the elbow. 

4 Burkhardt: Wurtemberg med. correspondenzblatt, 1878, No. 4, p. 35, quoted hy 
Poinsot in Eev. de Chirurgie, 1883, p. 629. 



TREATMENT. ^69 

months afterward the limb could be abducted 45°, and the hand placed 
on the opposite shoulder, on the top of the head, and behind the hips, but 
external rotation remained very limited. 

Burkhardt's is, then, the only successful case, for, although Albert 
effected reduction, he broke the humerus and got a false joint at the seat 
of fracture ; but still I think Albert's opinion that the security afforded 
by antiseptic methods of operating will lead surgeons to repeat the attempt 
will prove correct. Personally, I should resort to it in preference to forcible 
traction or subcutaneous division or resection. My only hesitation would 
arise from some doubt concerning the effect of the operation upon the 
vitality of the cartilage of incrustation. In a similar operation upon the 
elbow I had reason to think that the dissection of the capsule led to the 
destruction of much of the cartilage and to rarefaction of the epiphysis 
of the humerus. Perhaps this consequence would be avoided by leaving 
the periosteum untouched, and by dividing the adhesions and ligaments 
instead of dissecting them away from the bone. 

Excision of the head has been done in a few cases, among others by 
Edward Warren, Annandale, von Volkmann, and Oilier. 

Warren's operation was done in Baltimore in 1869. The following 
account is given by Gross : l " His patient was a female, fifty years of 
age, who, twelve months previously, in a fall, had luxated the humerus, 
throwing it down into the axilla beneath the coracoid process, in contact 
Avith the brachial plexus of nerves, occasioning violent and persistent 
pain, with great disability and gradual emaciation. The joint was ex- 
posed by a V-shaped incision, and the head of the bone, firmly wedged 
in its new position, divided through the surgical neck. The patient 
rapidly recovered with a good use of the arm.'' 

Annandale's 2 patient was a woman, sixty-two years old, with a sub- 
clavicular dislocation that had lasted six weeks and caused much pain. 
He made an incision along the anterior border of the deltoid, hoping to 
be able to free the head and replace it in its socket ; but finding this 
impossible, he divided the bone at the surgical neck and removed the 
head piecemeal : it was very firmly adherent to the ribs. During the 
operation he wounded the posterior circumflex artery and tied it, but the 
ligature cut through, and as the stump of the vessel was only one-eighth 
of an inch long, he tied the axillary artery above and below it. Gangrene 
of the limb ensued, and the patient died on the third day. 

Yolkmann's 3 patient was a man, fifty-five years old, with a subcoracoid 
dislocation of five weeks' standing, and very marked hard oedema of the 
lower part of the limb. Three attempts to reduce were made, but they 
resulted only in bringing the head into the axilla ; crepitation was per- 
ceived on certain movements, especially rotation. An incision was made 
in the axilla upon the head of the bone which, the arm being elevated, 
projected prominently under the skin ; a considerable amount of dark- 
brown, sero-sanguinolent liquid escaped through the incision, and the 
head was found lying in a cavity as large as the fist and filled with partly 

1 Surgery, 5th ed., vol. ii. p. 38. 

2 Annandale : Med. Times and Gaz., 1875, vol. i. p. 576. 

3 Volkmann : Centralblatt fur Chir., 1883, p. 28. 



270 DISLOCATIONS OF THE SHOULDER. 

clotted blood ; venous bleeding came from the bottom of the wound. 
The head was then separated by means of a chain-saw and removed, and 
the bleeding was found to come from an opening in the axillary vein, 
which was displaced toward the anterior wall of the axilla and lay so 
deep that a ligature could not be placed upon it until after the skin and 
pectoralis major had been divided at right angles to the first incision. 
The wound in the vein must have been caused either by the dislocation 
itself or by the attempts to reduce, and probably, it was thought, by the 
intervention of a sharp fragment of bone as large as the end of the finger, 
w T hich had been broken from the humerus at a point near the lesser 
tuberosity and, still adherent to the periosteum, lay in the cavity of the 
wound. Even after the excision the resistance of the soft parts was such 
that the limb could at first be brought only incompletely into position. 
The incision was closed with sutures ; three drainage tubes ; Lister 
dressing. Primary union took place, the temperature rising only once 
to 100J ° ; the oedema diminished, and the patient was discharged at the 
end of five weeks with good position and good passive mobility of the 
limb. The ultimate result is unknown. 

Oilier 1 attempted to reduce by arthrotomy an intracoracoid dislocation 
of nine months' standing, and, failing, did resection. He made an 
anterior incision. After resection a portion of the capsule was found 
bunched in the glenoid cavity ; even after the removal of the head it was 
difficult to bring the end of the shaft into contact with the glenoid cavity 
because of the retraction of the muscles. The ultimate result was good. 

Fracture of the surgical neck of the humerus, which has not infre- 
quently been caused by the attempts made to reduce, has sometimes been 
taken advantage of to place the limb in a better position, and Despres 2 
recommends that it should be intentionally produced. Others have done 
it with the view of subsequently preventing its reunion and establishing 
a false joint between the upper end of the shaft and the glenoid fossa. 
Despres's first operation (loc. cit., p. 22) was done with the view of 
obtaining a pseudarthrosis at the seat of fracture, but bony union took 
place. The usefulness of the limb was, however, so much increased by 
the change in its position that he repeated the operation upon another 
patient with the view of simply effecting this change, and was in this 
case also well satisfied with the result. The proposal to generalize the 
practice does not appear to have been received with much favor by his 
colleagues in the Society. A great objection to it as practised by him, 
in my opinion, was that he fractured the bone by forcibly abducting the 
elbow, using the edge of the acromion as a fulcrum ; he claims that the 
fragility of the bone is so much increased by the persistence of the dis- 
location that the fracture can be readily effected, and that after the 
fracture the head atrophies and its mobility in its abnormal position is 
thereby increased. However that may be, the manipulation is one that 
exposes to the danger of rupturing the vessels of the axilla, and that 
danger is too great to be offset by the comparatively slight improvement 
in the functions of the limb. 

1 Oilier: Eev. de Chirurgie, 188G, p. 904. 

2 Despres: Bull, de la Soc. de Chir., 1879, p. 742. 



CONGENITAL DISLOCATIONS. 



271 



Other features of this subject have been considered in the first part of 
this chapter. 

Dr. J. Ewing Mears 1 divided the surgical neck subcutaneously with an 
Adams's saw and obtained an excellent result by pseudarthrosis. His 
patient was a man, thirty-nine years of age, and the dislocation was of 
two years' standing. The saw was entered on the outer side, and the 
division was easily effected in about five minutes. The case deserves to 
be remembered, and the method is to be preferred to fracturing as less 
dangerous and more precise. 

Congenital Dislocations. 

Congenital dislocations are very rare, and even in many of the reported 
cases there is much uncertainty as to the correctness of the diagnosis if 
we exclude from this class those cases in which a dislocation is produced 
during delivery. There is good reason to think that cases are reported 
as congenital with no better reason for the opinion than the facts that the 
dislocation has been discovered at an earlv age and that there is no historv 



Fig. 68. 



Fig 






The same ; left humerus. 



of a traumatic cause. Conse- 
quently there may be, and doubt- 
less are, included traumatic cases 
occurring at the time of birth and 
paralytic cases of infancy, espe- 
cially the so-called ''obstetrical 
paralyses " (vide infra), and some 
doubt is thus cast upon all re- 
ported cases. 
Kronlein says that of 98 congenital dislocations treated in von 

Langenbeck's poliklinik, 90 were of the hip, 5 of the shoulder, 2 of the 

head of the radius, and 1 of the knee. 

It is probable that the cause is an arrest of development, as has been 

so well proved for congenital dislocations of the hip, and the opinion ' 

1 Mears : Philadelphia Med. and Surg. Eeporter, 1877, vol. xxxvii. p. 287. 



R. W. Smith's case of double congenital subcoracoid 
dislocation of the shoulder. Scapula of left side. 



IS 



272 



DISLOCATIONS OF THE SHOULDER. 



supported by the facts that the lesion is often double and often associated 
with other congenital defects ; thus, R. W. Smith 1 saw one case in which 
there were double subcoracoid, and another in which there were double 
subacromial dislocations, and a third in which there was a subcoracoid 
dislocation with clubfoot on the same side. Kronlein 2 saw a subacromial 
dislocation associated with congenital dislocation forward of the head of 
the radius on the same, side, and another with rudimentary development 
of the radius. 

The varieties that have been observed are the subcoracoid and the sub- 
acromial, and perhaps the subspinous (Gaillard). For an account of the 
pathological changes we are indebted almost exclusively to R. W. Smith. 
In his case of double subcoracoid dislocation, a lunatic woman twenty- 
nine years old, "there existed on the left side scarcely any trace of an 
articulating surface in the situation which the glenoid cavity occupies in the 
normal state ; but there had been formed upon the costal surface of the 
scapula a socket of a glenoid shape, measuring about an inch and a half 
in its vertical direction and an inch and a quarter transversely (Fig. 68). 
It reached upward to the under surface of the coracoid process, from 
which the head of the humerus was merely separated by the capsular 



Fig. 70. 



Fig. 71. 





The same ; right humerus. 

ligament." The glenoid liga- 
ment, perfect in every re- 
spect, extended all around it. 
The capsule was perfect. 

The head of the humerus 
(Fig. 69) " was of an oval 
shape, its long axis corre- 
sponding with the shaft of 
the bone. The oval shape 
was principally due to the deficiency of its posterior part, and there existed 
between the greater tubercle and the margin of the head of the bone, 



The same ; right scapula. 



1 R. W. Smith : Fractures and Dislocations, 1847, p. 256. 

2 Kronlein : Deutsche Chirurgie, Lief. 26, p. 97. 



CONGENITAL DISLOCATIONS. 



273 



where the investing cartilage terminated, a broad, shallow depression, 
corresponding to the edge which separated the normal from the abnormal 
portion of the glenoid cavity. The shaft of the humerus was small and 
seemingly atrophied." 

Upon the right side, although the condition of the bone was somewhat 
different the characteristic features of the deformity were similar. (Figs. 
70 and 71.) 

In his double subacromial case, a lunatic woman forty-two years old, 
" there was no trace of a glenoid cavity in the natural situation ; but 
upon the external surface of the neck of the scapula there was a well- 
formed socket which received the head of the humerus (Fig. 72). It 

Fig. 72. 





Double congenital, subacromial dislocation. (R.W.Smith.) 



was an inch and three-quarters in length, and an inch in breadth ; it 
was a little broader above than below, and its summit was less than a 
quarter of an inch from the under surface of the acromion process. It 
was directed outward and forward, was covered with cartilage, and sur- 
rounded by a perfect glenoid ligament. The tendon of the biceps muscle 
arose from the most internal part of its superior extremity, whence it 
passed downward and outward very obliquely, in order to reach the 
bicipital groove of the humerus. The axillary margin of the scapula, if 
prolonged upward, would have passed nearly altogether internal to the 
abnormal socket. . . . The capsular ligament was perfect. The 
scapula was smaller than natural, and its muscles badly developed." 

" The head of the humerus (Figs. 73 and 74), upon the right side, was 
of an oval or oblong form, somewhat broader above than below ; its 

18 



274 



DISLOCATIONS OF THE SHOULDER 



anterior half alone was in contact with the glenoid cavity. This portion 
was covered with cartilage, the remaining half being rough and scabrous, 
and totally destitute of articular cartilage. The inner edge of the 
humerus, if prolonged upward, would have passed between these two 
portions of the head of the bone." 



Fig. 73. 



Fig. 74. 





R. W. Smith's case of double congenital subacromial 
dislocation of the shoulder ; right humerus. 



The same ; left humerus 



" The greater tubercle was natural, but the lesser was elongated and 
curved, forming a most remarkable process : it was an inch in length, 
and bore some resemblance to the coracoid process of the scapula. At 
its root it presented a smooth, convex, pulley-shaped surface, round 
which passed the tendon of the biceps muscle." The left humerus 
differed from the right only in the smaller size of the lesser tuberosity. 

Both these cases were first seen by Smith upon the autopsy-table, and 
he gives no history as to the length of time the deformity had lasted. 
Both individuals had been for many years inmates of the lunatic asylum, 
and the second one was subject to epileptic convulsions, in one of which 
she died. It must be admitted that the appearances are not incompatible 
with the theory of a post-natal origin, perhaps by muscular action in an 
epileptic convulsion, as in Frankel's case of double simultaneous disloca- 
tion quoted above, p. 260. Kuster's case of supposed congenital double 
dislocation backward in a child fourteen months old, with the autopsy, 
has been quoted in Chapter XVII.; in it each glenoid fossa was normally 
placed and shaped, but small, and the humerus rested on its posterior 
border, the limb being strongly rotated inward ; a condition which, in my 
opinion, is much more suggestive of a traumatic or paralytic (vide infra) 
origin than of pre-natal arrest of development. 

The three cases of single subcoracoid dislocation observed during life 
by Smith presented the same appearances. The muscles of the shoulder 
and arm were notably wasted, with the exception of the trapezius, and 
the wasting extended to the muscles which pass from the side of the 



CONGENITAL DISLOCATIONS. 275 

chest to the humerus and scapula, so that the thorax on the dislocated 
side measured one inch and a half less in circumference than on the other. 
The motions of the limb were extremely limited; as it hung by the side 
it could only be swung backward and forward, and even in that motion 
the scapula largely participated; active abduction or elevation was 
entirely lost, and passive abduction was slight. The scapula was more 
freely movable upon the chest than usual. The muscles of the forearm 
were wasted, but not so much so as those of the arm. 

The head of the humerus presented nearly its natural form, so far as 
could be ascertained ; it could be easily pressed inward or outward. The 
acromion was prominent, and the thumb could be easily inserted between 
it and the head of the humerus. The shoulder did not present its natural 
rounded form, but was not so much flattened as in traumatic dislocations. 

The history of his third case, a boy nine years old, is in part as 
follows (loc. cit., p. 261): "The aunt of the child stated that his right 
arm was paralyzed, but the peculiar and characteristic manner in which 
the limb hung by his side induced me to suspect the existence of an 
original malformation of the shoulder-joint. It was stated that he had 
nearly attained the age of one year before the condition of the limb 
attracted attention, which w T as then excited, not by the deformity of the 
shoulder, but by the atrophied condition of the muscles of the arm, when 
contrasted with those of the opposite side. The child had not met with 
any accident, nor did he ever complain of pain or of any other symptom 
indicative of disease of the articulation. . . . I inquired particularly 
whether the deformity of the shoulder had increased since it had first 
been observed, and learned that several years had elapsed before the full 
development of the appearances which the joint now presented." 

In his subacromial case the coracoid process and the anterior margin 
of the coraco-acromial ligament stood out in strong relief ; the acromion 
process was unusually prominent, but not so much so as in accidental 
dislocations. The shoulder appeared higher than natural, and was flat- 
tened anteriorly ; posteriorly a round solid tumor plainly indicated the 
situation of the head of the humerus. The arm was directed obliquely 
downward and inward ; the elbow was in contact with the side, and the 
hand and forearm pronated. 

Gaillard's case of subspinous dislocation, quoted by Malgaigne, loc. 
cit., p. 569, is as follows. The patient was a girl sixteen years old. 
A few days after birth it was noticed that the left arm was deformed and 
the elbow abducted ; later the arm was immovable. The dislocation was 
not recognized until she was four years old. When she came under 
Gaillard's care, at the age of sixteen, the head of the humerus lay in the 
subspinous fossa at about an equal distance from the two ends of the 
spine of the scapula. The scapula and clavicle had suffered an arrest of 
development ; the arm was thin and four centimetres shorter than the 
other ; the forearm was well developed, but could not be completely 
extended or supinated. Four times in the course of a week Gaillard 
made horizontal traction on the arm by means of a weight of sixteen 
pounds, continued for fifteen or twenty minutes, and reinforced occasion- 
ally by traction with his hands. On the last occasion the head moved 
an inch and a half along the scapula to the edge of the glenoid fossa and 



276 DISLOCATIONS OF THE SHOULDER. 

was then thrown into it by a movement of leverage. It almost imme- 
diately came out again. The next day it was again reduced and kept in 
place for a hour. Ten days later it was again reduced, and the arm fixed 
by a bandage ; this time the reduction persisted. Two years later the 
limb was found- to have gained half an inch in length ; the patient could 
move it inward, outward, forward, and backward, could lace her clothes 
behind her back, carry a chair, feed herself, and play on a guitar. 
Possibly this also was a case of dislocation by obstetrical paralysis (vide 
infra). 

The only case within my knowledge in which an operation was under- 
taken was Krister's (quoted above, Chap. XVII., p. 244) ; he excised the 
head of the humerus in a subacromial dislocation in a child fourteen 
months old ; the case terminated fatally. 

The prognosis is unfavorable as regards reduction or benefit by opera- 
tion ; if the glenoid fossa does not exist there can be no question of 
returning the head of the humerus to it, and an operation can only place 
the limb in a position where its range of motion will be more free; it 
will always be doubtful whether the long disused or paralyzed muscles 
will regain an active control over it. 

Pathological Dislocations and Subluxations. 

Subluxation or complete dislocation may be made easy by changes 
effected in the articular surfaces or the capsule by disease, or by paralysis of 
the deltoid or rotator muscles which normally aid in maintaining the close 
contact between the bones. The reported instances are not very numerous, 
and even in some of these the evidence, clinical or post-mortem, has left 
not only the character and extent of the displacement in doubt, but also 
its essential cause. Such cases do duty with the different writers as 
supposed examples of widely different lesions, such as partial traumatic 
dislocations, new forms of dislocation, and chronic arthritis. Gurlt 1 
gives to Adams (Todd's Cyclopaedia, article Shoulder-joint^ and Canton 
(London Med. Gazette, 1848, vol. b\ p. 410, and vol. 8, p. Ill) the 
credit of having first shown that cases described as partial dislocation by 
Sir Astley Cooper, Hargrave, and others were actually examples of 
chronic non-suppurative arthritis. In his own description of the changes 
effected by this disease in the quoted cases he does not always discriminate 
between those which were the effect of the prolonged inflammation and 
those which should probably be attributed to an antecedent traumatic 
dislocation Avhich originated the process, such as rupture of the tendons 
of the supra- and infra-spinatus and subscapularis muscles, and the estab- 
lishment of a large opening between the cavity of the joint and the sub- 
acromial bursa. A dislocation recurring after such injuries should be 
classed with the " habitual dislocations.'" 

Of the three classes made by Volkmann — dislocations by distention, 
by destruction, and by deformity (see Chapter X.) — the second is by far 
the most rare, and the third apparently the most common, although the 
distinction between the latter and the first cannot always be determined 

1 Gurlt: Patholog. Annt. der Gelenkkrankheiten, 1853, p. 250. 



PATHOLOGICAL DISLOCATIONS AND SUBLUXATIONS. 277 

clinically. Indeed, I know of only one recorded case in which the his- 
tory clearly shows an acute non-traumatic effusion in the joint promptly 
followed by an abrupt appearance of the deformity with instant relief 
of the pain, such as has been observed at the hip and knee in the course 
of acute rheumatism or the eruptive fevers. At the shoulder the effusion 
has taken place more slowly, usually as the result of a traumatism, and 
the dislocation has been partial; in traumatic cases there is always the 
possibility that the ligaments may have been torn or the bones chipped 
in such a way as to facilitate dislocation. The case referred to was 
reported by Hannon and is quoted by Malgaigne (loc. cit., p. 562). A 
man forty-five years old, who had previously suffered with acute rheuma- 
tism in the knee and hip, became feverish, and on the following day had 
an acute inflammation of the shoulder-joint. The pain increased, and on 
the night between the fifth and sixth days became suddenly very severe ; 
the next morning a subcoracoid dislocation was found, and was reduced 
with some relief of the pain. The next day the dislocation was found 
to have partially recurred ; it was again reduced, and the limb fixed with 
a bandage. Recovery followed. 

Malgaigne thinks the over-distended capsule is ruptured on the inner 
side, and thus the dislocation made possible ; the view seems insufficient 
to explain the easy partial recurrence. When the effusion is more slowly 
produced and is large the head of the humerus is separated from direct 
contact with the glenoid cavity by a layer of liquid, the depth of which 
may amount [to one centimetre (Albert, loc. cit., p. 320), under which 
circumstances it is evident that a slight force would be sufficient to dis- 
place the humerus to either side and without rupture of the capsule, just 
as one easily produces a dislocation in a freshly dissected shoulder after 
making a small opening in the capsule to admit the air. This requires 
relaxation of the scapular muscles which normally hold the bones close 
together, and such relaxation would not be found when the arthritis is 
acute and painful. In Lesauvage's 1 case the dislocation did not take 
place until ten years after the beginning of the arthritis and three years 
after a marked exacerbation had begun which lasted until the dislocation 
(subcoracoid) occurred. 

A class of cases, of which quite a number have been reported, are 
sometimes described as traumatic dislocations upward, but Malgaigne's 
opinion that they are the result of arthritis is now generally accepted for 
most of them. They are characterized by the projection of the head 
upward and forward and rigidity of the limb. Malgaigne quotes a case 
to show that- the displacement may be caused by carrying the arm in a 
sling that is too short and tight. 

Most of the specimens of dislocation by deformity are open to the doubt 
whether they may not actually be nearthroses following traumatic dislo- 
cation, and this is especially true of those in which the dislocation is 
forward. Grurlt (loc. cit., p. 274) describes seventeen specimens concern- 
ing which this doubt exists, and I think he might well have added to 
them several of those which he describes as examples of chronic inflam- 
mation. The following are examples of the different forms. 

1 Lesauvage : Arch. gen. de Med., 183-5, vol. 9, p. 261. 






278 DISLOCATIONS OF THE SHOULDEK. 

Dislocation downward, forward, and inward. (Gurlt, loc. cit., p. 276, 
No. 3. From Museum of Royal College of Surgeons, No. 3275.) The 
head of the humerus is flattened and enlarged, and its articular surface 
rests upon a deep concave surface composed of new bone deposited upon 
the anterior and under portion of the scapula immediately below and 
upon the inner side of the glenoid fossa. A large irregular prominence 
of new bone extends from the greater tuberosity upward and backward, 
and it is probable that the elongated supra- and infra-spinatus muscles 
were attached to it. The glenoid fossa has lost its original form ; its 
border and surface are irregular, and its cartilage is entirely lacking. 
The humerus appears to have been freely movable. (Gurlt speaks of it 
as a somewhat doubtful case.) 

Partial subglenoid dislocation. (Gurlt, loc. cit., p. 266, No. 22. 
Quoted from Adams, in Todd's Cyclopaedia, art. Shoulder-joint, p. 599.) 
The head of the humerus lies so far below its usual position that a new 
socket has formed upon the axillary border of the scapula. The original 
socket is still in part occupied by the enlarged head of the humerus. The 
glenoid fossa is enlarged downward one and a half inches below its usual 
space. The new cavity is smooth, and enlarged on its posterior border 
by several irregular masses of bone. The capsular ligament is in part 
ossified. 

Dislocation backward, on both sides. (Gurlt, loc. cit., p. 266, No. 20. 
From St. Bartholomew's Hospital, series II., subseries B, No. 32.) The 
heads of the humeri are flattened and enlarged by bony outgrowths about 
their edges ; the glenoid fossae are also correspondingly enlarged and 
deepened, and extend backward and inw T ard to the spina scapulae ; they 
are hard, perforated by numerous holes, and smooth in places. The 
changes are symmetrical in the two joints, except that the surfaces on the 
right side are smoother. 

Dislocations due to Paralysis. 

This variety, rare in the adult, has been shown by the investigations 
of Duchenne de Boulogne 1 to be much more common in newborn children, 
the paralysis being due to the pressure of the forceps or to traction in 
delivery. In consequence of the lack of support which ensues upon the 
paralysis of the muscles of the shoulder, the weight of the limb causes it to 
sink downward, the only remaining support, that of atmospheric pressure, 
being presumably overcome gradually by the accumulation of liquid 
within the capsule. The condition of the joint then resembles that of 
hydrarthrosis, plus the relaxation of the muscles, and, as has been above 
described, any slight force is then sufficient to displace the head of the 
humerus to one side. Malgaigne says that when all the muscles of the 
shoulder are paralyzed the displacement is always downward and forward, 
and usually incomplete ; and that when the paralysis is partial the dis- 
placement is always effected by the action of the unparalyzed muscles 
and is reduced by the weight of the limb ; in the only cases of the latter 

i Duchenne de Boulogne: De l'Electrisation localisee, 1871, 2d ed., and Pan as 
Diet, de med. et chir. pratiques, art. Epaule, p. 514. 



DISLOCATIONS DUE TO PARALYSIS. 279 

kind of which he had knowledge, two in number, the displacement was 
backward. He saw in a man, thirty-four years old, a double paralytic 
dislocation. 

In newborn children the dislocation is said to be always backward, 
subacromial. Duchenne saw in ten years eight cases of this kind. In 
all the cases of obstetrical paralysis which he had seen the same group of 
muscles was affected, namely, the deltoid, infraspinatus, biceps, and 
brachialis anticus ; in some there was also paralysis of the muscles in the 
forearm and hand supplied by the musculo-spiral or ulnar nerve. I have 
seen paralysis of the same muscles (the deltoid, biceps, and brachialis 
anticus) appear spontaneously at the age of one year, with consequent 
laxity of the joint that permitted dislocation forward and backward. I 
have seen only one case of subacromial dislocation dating from about the 
time of birth. The delivery had been effected with forceps. When 
the paralysis is caused by the application of the forceps the mechanism 
appears to be the pressure of the edge of the instrument upon the brachial 
plexus on the side of the neck ; in other cases it is the pressure of the 
finger used as a hook in the axilla or to bring down the arm when raised 
beside the head. 

In one of Duchenne's cases, treated by Chassaignac, a permanent cure 
was obtained by a fixation dressing, worn for five or six weeks. 

Occasionally the disability of the muscles is due to a traumatism (myo- 
pathic dislocation). In a case reported by Wolff, 1 in which the head of 
the humerus had sunk almost three centimetres below the acromion, and 
the disability was very great, the functions of the limb were much improved 
by an operation ; the joint was opened posteriorly along the margin of 
the glenoid fossa, the articular cartilage removed, and the bones fastened 
together with strong silver wire. The control over the limb thus obtained 
through the scapula was such that it could be raised and lowered and 
even a little adducted and abducted. 

i Wolff: Berl. klin. Wochenschrift, 1886, No. 52. Abstract in Centblatt. fur Chir., 
1887, p. 637. 



CHAPTER XIX. 



DISLOCATIONS OF THE ELBOW. 



DISLOCATIONS OF BOTH BONES BACKWARD, FORWARD, LATERAL, 

DIVERGENT. 

Anatomy. — On either side of the lower end of the humerus is a 
prominence, the epicondyle, which can be easily felt, and is of great 
importance in the recognition of any change in the relations of the 
bones that constitute the elbow-joint. The inner one, commonly called 
the epitrochlea, is more prominent and well-defined than the outer one, 
and its upper margin joins the shaft of the humerus by a sharp curve, 
while on the outer side of the shaft the supinator ridge connects the 
side of the shaft with the epicondyle by a gradual slope. Below the 
epitrochlea is the flattened circular side of the trochlea, projecting down- 
ward and forward about half an inch, with a sharp, well-defined margin, 
which is masked by the olecranon and ulna when the bones are in place. 
From this edge the articular surface of the trochlea passes outward like 
a cone, its diameter becoming rapidly smaller for about half an inch, 
and then enlarges again, but less abruptly, for nearly an equal distance. 
Above it, posteriorly, is a deep depression, the olecranon fossa, into 
which the tip of the olecranon is received in full extension of the joint, 
and above it, anteriorly, is a corresponding, smaller one, to receive the 
tip of the coronoid process in full flexion. On the outer side of the 
anterior and lower part of the trochlea, and separated from it by a shallow 
vertical groove, is the capitellum, or radial head, of the humerus with 
which the head of the radius articulates, a rounded prominence looking 
directly forward. 

The ulna articulates with the trochlea by its greater sigmoid cavity, 
which is concave from above downward and has a central longitudinal 
ridge which fits like a wedge into the central depression of the trochlea, 
or like a rope into the groove of the wheel of a pulley, and thus opposes 
displacement to either side. The posterior end of the concavity is formed 
by the tip ■ of the olecranon, the anterior end by the coronoid process. 

The radius articulates with the capitellum by the slightly concave, 
circular upper surface of its cylindrical head, and with the lesser sigmoid 
cavity on the outer side of the ulna and coracoid process by the side of 
its head. This articular surface on the side of the head is about three- 
eighths of an inch long (from above downward) on the inner and posterior 
side of the bone, the part that is in contact with the ulna in supination, 
but is shorter on the outer side at the part which comes in contact w T ith 
the ulna in pronation. 

The long axes of the trochlear cones and the ovoid capitellum coincide 
with one another and represent the axis of the joint for flexion and 



DISLOCATIONS OF BOTH BONES BACKWARD. 



281 



Fig. 75. 



extension ; this line crosses the lower end of the humerus from a point 
just below and in front of the external epicondyle to one that is just 
covered by the lower part of the epitrochlea, and is inclined downward 
and inward from the transverse axis of the lower end of the humerus, so 
that the long axis of the forearm does not coincide with that of the arm 
but deviates to the outer side as it passes downward. 

When the bones are in place and the forearm fully extended the upper- 
most part of the olecranon, the "point of the elbow," lies on or close 
below a transverse line drawn behind the limb from the epitrochlea to the 
epicondyle ; and when the elbow is flexed at a right angle the same point 
lies a little more than an inch directly below and nearly midway between 
these two prominences in the prolongation of the long axis of the shaft 
of the humerus. Ordinarily the 
relations of these three points to 
one another can be readily deter- ||j|i 

mined, even when the region is /' 

swollen, and they are the most JB 

convenient and trustworthy aid in ; v 1 

the recognition of the existence JfiH 

of a dislocation of the ulna. JJt 1 

The outer border of the head 
of the radius can be felt about 
three-quarters of an inch below 
the epicondyle in a line drawn 
from the latter to the wrist, and it 
can be felt to move when the 
hand is gently rotated. This is 
the only point where the inter- 
articularline is distinctly accessible 
to palpation ; at all other points it 
is too thickly covered by soft parts 
or masked by the parallelism and 
close contact of adjoining surfaces. 

The internal lateral ligament 
arises above from the anterior, 
lower, and posterior portion of the 
epitrochlea and is 'broadly inserted 
below along the inner margin of 
the greater sigmoid cavity. 

The external lateral ligament, shorter and narrower than the internal, 
arises above just below the epicondyle and becomes blended below with 
the orbicular ligament that surrounds the head of the radius, some of its 
posterior fibres being continued to the ulna. 

The anterior and posterior ligaments are thin and loose, and close in 
the joint between the lateral ligaments in front and behind, respectively. 

The orbicular, or annular, ligament, placed like a ring about the head 
of the radius and the adjoining portion of its neck, occupies three-fourths 
of a circle of which the remaining fourth is formed by the lesser sigmoid 
cavity of the ulna ; k is thus attached by its two ends to the ulna and 
encircles the head of the radius. It is reinforced externally and 




The bones of the elbow. B, the axis of motion. 
(Tillaux.) 



282 



DISLOCATIONS OF THE ELBOW 



posteriorly by the fibres of the external lateral ligament. The synovial 
sac extends beyond its lower border for a short distance along the neck 
of the radius, and is then reflected upward and attached to this bone. 

The capsule forms a single, completely closed sac, enveloping all parts 
of the joint and extending above the olecranon and coracoid fossae. 
Some of the deepest fibres of the triceps and brachialis anticus are 
attached to it and draw it out of the way when it is relaxed in flexion 
or extension. 

The ulnar nerve passes close behind the joint on the inner side between 
the olecranon and epitrochlea in close relations with the capsule and 
lateral ligament. 

The movements of the joint are flexion and extension, which, strictly 
speaking, are provided for by the humero-ulnar articulation, and rotation 
of the forearm, which belongs to the radio-ulnar joints. The relations 
of the head of the radius to the humerus give greater breadth to the 
joint and thus secure it more effectually against angular lateral motion. 
Flexion is arrested by the interposition of the soft parts between the 
bones in front or, if pushed to the extreme, by the contact of the tip of 
the coracoid process with the humerus. Extension is arrested by the 
tension of the ligaments and muscles on the front of the joint and by 
the contact of the tip of the olecranon with the back of the humerus. 
Lateral angular motion is prevented by the lateral ligaments. 

Frequency.— hi order of frequency the dislocations of the elbow 
come next after those of the shoulder. The Tables in Chapter I. in 
which both hospital and polyclinic cases are included show percentages 
varying from 27 (Kronlein, 109 in a total of 400) to 16 (Prahl, 69 in a 
total of 420). Table III., in which several statistics are combined, gives 
315 cases in a total of 1432, or 22 per cent., for combined hospital and 
polyclinic service, while 964 hospital cases give only 97, or 10 per cent. 

Kronlein's 109 cases arranged according to age, sex, and variety are 
as follows : 



Table XI. — 109 Dislocations of the Elbow. (Kronlein.) 





Sex. 


Age. 


Variety. 


M. 


F. 


1-10 


11-20 


21-30 


31-40 


41-50 


51-60 


61-70 


71-80 


Forearm, backward 

Radius, alone 


77 
9 


17 
6 


22 
9 


44 
5 


14 

1 


5 


4 


3 

... 


1 

... 


1 



This shows the same preponderance in males over females, 4 to 1, 
that is shown by dislocations in general, and that the great majority, 80 
out of 109, occur during the first twenty-four years of life. Attention 
was called in Chapter XVI. to the difference in respect of age between 
dislocations of the elbow and those of the shoulder, the latter being rare 
at the age when the former are common, and most frequent in middle 
life ; and Kronlein's opinion was there quoted that fractures of the clavicle 
are in childhood the equivalent injury — that is, are produced by the same 
cause — of dislocations of the shoulder by direct violence in middle life, 



DISLOCATION OF BOTH BONES BACKWARD. 



283 



and that dislocations of the elbow are the equivalent injury of disloca- 
tions of the shoulder by indirect violence. 

Classification. — The diiferent forms of dislocation of the elbow are 
numerous, for the two bones of the forearm may be displaced together in 
any one of the four principal directions, or each may take a different 
direction, or either may be dislocated while the other remains in place. 
The number of named forms has been still further increased by making 
in some a distinction between "complete" and "incomplete" which not 
only is not justified by any corresponding important pathological or 
clinical difference, but which also does not even correspond with the defi- 
nition of " incomplete" given by those who make most use of the term. 

The following table prepared by Denuce 1 in 1869, and reprinted by 
Pingaud 2 in 1878, gives in a convenient form most of the varieties thus 
far observed ; it is reproduced here because of the prominence given to 
it by its publication in these two important works, and because of the 
frequent references to it in current literature, but it must be regarded 
rather as a working schedule or table of contents prepared for convenience 
of reference than as a complete classification or even as an accurate one 
within its own limits. While some of its subdivisions are created on the 
authority of single, and more or less doubtful cases, others are made to 
include cases that differ quite as much from one another as do those that 
are separately classified. 



Classification of Dislocations at the Elbow. (Denuce/ 



Dislocations of 
the forearm 
upon the arm, 



Dislocations of 
the ulna alone, 



A. Backward, 



B. Forward, 



C. Outward, 



D. Inward, 



Ulna back- 
ward, 





A. 


Radius 

backward, 


Dislocations of 






the radius 


B. 


Radius 


alone, 




forward, 




C. 


Of the radius 



cation of children. 



f Complete. 

Incomplete. 

Backward and outward. 

Backward and inward. 
v Backward, complicated with fracture. 

Complete. 

Incomplete. 

Forward and outward. 

Forward, complicated with fracture. 
I Complete. 

Incomplete. 
! Outward, complicated with fracture. 

Incomplete. 

Inward, complicated with fracture. 

Complete. 
Incomplete. 
Backward and inward. 
Backward and outward. 

Complete. 
Incomplete. 

Backward and outward. 
Complete. 
Incomplete. 
Forward and outward, 
bv elongation, or the incomplete dislo- 



1 Denuce: Diet, de Med. et Chir. pratiques, art. Conde. 

2 Pingaud: Diet, encyclopedique des Sci. Med., art. Co de. 



284 



DISLOCATIONS OF THE ELBOW. 



4 S' Its m {A. Dislocation of the ulna backward and of the radius 

,i,i \ B. Dislocation of the ulna backward and of the radius 



outward. 



Many of these varieties are closely allied to one another, and produced 
by causes that differ very slightly. Thus, if the joint is hyper-extended, 
the ligaments torn, and a backward dislocation of both bones begun, the 
final position taken will vary with the direction in which the force con- 
tinues to act, and with the addition to it of lateral flexion of the joint or 
rotation of the forearm, so that forms as widely different in appearance 
as direct backward dislocation, lateral dislocation, and divergent disloca- 
tion may be produced. It will be proper, therefore, as well as convenient, 
to describe under the more common type, backward dislocation of both 
bones, much that concerns many of the other forms, and to limit the 
descriptions of the latter mainly to the points of difference. 

The classification which will be here followed is the same in its prin- 
cipal features as the above and as those adopted by most recent writers. 
The differences are in the grouping and recognition of the varieties. 



Dislocations backward. 

backward and outward. 

backward and inward. 

Lateral dislocations, 

! , ( inward, 
incomplete | outward> 

complete outward. 
Forward dislocations, 

incomplete, or 1st degree. 

complete, or 2d degree. 

with fracture of the olecranon. 
Divergent dislocations, 

antero-posterior. 

transverse. 



Dislocations of 
the forearm on 
the arm, 



3. 



Dislocations of 
the ulna alone. 



Dislocations of 
the radius alone, 



Congenital and 
pathological 
dislocations. 



1, 

3. 

It 



^ i -, -, , fl. Incomplete, or 1st degree. 

2. Backward and upward, j % Compl £ te) ^ r 2d degr ° ee . 

Backward and outward, behind radius. 

Backward. 

Outward. 

Forward. 

By elongation, or the subluxation of children. 

Associated with fracture of the ulna. 



1 This variety rests upon a single reported case (Cooper: Disloc. and Fracts., Am. 
ed., 1844, p. 384), a compound dislocation quoted by Cooper as a dislocation back- 
ward. It does not appear from the account that the radius and ulna were separated 
from each other, and consequently this classification is misleading. It should not 
be confounded with Malgaigne's " dislocation of the ulna backward and to the out- 
side of the radius," which is bracketed by him with the above variety A, class 4, to 
form a class entitled " Double dislocation of the ulna upon the humerus and radius," 
but which is more properly placed by Denuce in class 2, dislocations of the ulna 
alone, 4th variety, backward and outward, the mechanism of which is torsion (pro- 
nation) of the forearm about the radius, by which the ulna is carried backward and 
outward. 



dislocations of the forearm backward. 285 

Dislocations of the Forearm Backward. 

This is the most common of all the dislocations of the elbow. It is 
habitually produced by a fall, but although the examples are so numerous 
the mechanism or mode of production has been the subject of much con- 
troversy, largely due to the resort to hypotheses which was stimulated by 
the lack of definite knowledge. Few who fall are able to describe the 
circumstances of the fall, to say whether the arm was fully extended or 
partly flexed, whether the violence was received upon the hand or upon 
the elbow, and a preconceived theory in the mind of the surgeon is a 
great help to the discovery of facts that favor it. 

The theory of production by forced flexion is supported, so far as I 
know, by only one case, and that a case that has only recently been 
reported. Stetter 1 had a patient who, while working in a mine, was 
caught under a falling stone in such a way that his left elbow was forcibly 
flexed between the stone and the wall and was dislocated backward. 
When seen, about an hour afterward, the joint was in the position of 
extension. Reduction was easily effected by traction, and recovery took 
place without incident. Fracture of the coronoid process could not be 
recognized. 

The theory of direct displacement backward (" glissement ") formulated 
by Boyer, and at one time widely held, has not withstood the criticism 
of later writers and is no longer accepted in explanation of dislocations 
caused by falls. A case reported by Weber nearly fifty years ago, and 
much quoted since, is an example of production in this manner, but not 
in a fall : a young man, wishing to show his strength, held his arm 
extended while another tried to bend it; the latter not succeeding, struck 
the front of the upper part of the forearm violently with his fist, at the 
same time pressing the wrist forward, and caused a dislocation which 
could not be reduced. In like manner, the dislocation can be produced 
by a blow upon the back of the arm just above the elbow, as in a case 
quoted by Malgaigne from Flaubert, in which the patient's arm was 
caught under an overturned wagon, and in another seen by Hamilton. 
A similar mechanism has also been observed in outward dislocation. 

The theory of torsion presented by Malgaigne, according to which the 
patient in his fall strikes upon the inner side of the slightly flexed forearm 
and the elbow, the limb being somewhat abducted, is perhaps true of 
some cases. Malgaigne's explanation is very brief; he simply says the 
dislocation is effected by "a movement of torsion which brings the coro- 
noid process successively inward, downward, and backward." Pingaud 
(loc. cit., p. 601) describes it in detail. He says that " at the moment 
the inner and posterior part of the elbow strikes the ground the humerus, 
under the influence of the weight of the body, tilts outward, and the ulna, 
pressed against the ground, turns in the opposite direction (pronation). 
From this result: 1st, rupture of the internal lateral ligament; 2d, sepa- 
ration of the articular surfaces on the inner side ; 3d, a torsion inward of 
the forearm about its axis.'" The details of this torsion into which he 
enters are far from clear, but the outcome is that, the bones being sepa- 

1 Stetter: Compendium der Lehre von den Luxationen, 1886, p. 43. 



286 DISLOCATIONS OF THE ELBOW. 

rated on the inner side, the coronoid process slips back behind the trochlea, 
or the latter turns forward over the former, and then as the limb untwists 
itself the radius also passes behind the humerus. He adds that the 
latter part of the process is open to modifications which result in a great 
variety of displacements. However obscure the explanation may be, and 
it suggests an origin in speculation rather than in observation, the fact 
remains that in a few well-authenticated cases the violence has certainly 
been received upon the upper and inner part of the forearm and not upon 
the palm of the hand. Pingaud (loc. cit., p. 496) quotes three such : a 
rider falling with his horse and dislocating his elbow while the hand still 
held the bridle ; a man falling in the gymnasium with his forearm bent 
behind his back ; another falling backward and rolling upon his side while 
his hand held his cloak together in front of his chest. 

Hyper extension. — It is now generally believed that the injury is 
habitually caused by a fall upon the palm of the outstretched hand, the 
elbow being in complete extension, and that the primary rupture of the 
ligaments which makes the dislocation possible is effected by hyperexten- 
sion of the joint. That this was a possible cause was known to Petit, 
who had seen a compound dislocation thus produced ; and Desault and 
Bichat, anticipating in this, as in so many other things, the slower judg- 
ment of the profession, declared it to be the common mechanism, but the 
investigations which first satisfactorily demonstrated it were made by a 
young German surgeon in 1844, Roser. 1 His results were quoted and 
his experiments repeated and extended to other than backward disloca- 
tions by Streubel, 2 and to these two papers and the articles by Denuce 
and Pingaud, above mentioned, the reader is referred for details to which 
the needed space cannot here be given. 

Experiment upon the cadaver shows that when this action, of a fall 
upon the outstretched hand, is imitated, the hand being supinated, the 
anterior portion of the internal lateral ligament becomes tense and then 
yields, usually at its upper insertion; then, as the movement is continued, 
the rupture extends along the anterior ligament, perhaps involving part 
of the brachialis anticus, the elbow bends inward, and if pressure is made 
downward upon the head of the humerus this bone passes down in front of 
the coronoid process and radius, and a backward dislocation is produced. 
A dislocation can in this way be easily produced upon the cadaver, and 
the temptation to infer that it correctly represents what occurs in a fall 
upon the hand is great. It is defective in not fully reproducing the 
action of the weight of the body upon the limb, and the reference of the 
effect solely to hyperextension is, I think, too exclusive. In the few 
cases in which I have been able to determine with any degree of cer- 
tainty the position of the limb at the moment of the fall, it has seemed 
probable that the arm was abducted or thrown backward, not stretched 
out in front, that is, that its position was such that the hand would be 
more or less supinated in the effort to prevent the body from striking the 
ground. In this position, the normal outward deviation of the radius 
from the axis of the humerus is greatest, and the resistance transmitted 

1 Koser: Arch, fur physiolog. Heilkiinde, 1844, Heft 2, p. 185. 

2 Streubel : Prager Vierteljahrschrift, 1850, vol. i. p. 1. 



DISLOCATIONS OF THE FOREARM BACKWARD. 287 

through it tends to increase the angle of deviation, and subject the 
internal lateral ligament to a rupturing strain. If it yields, the angle is 
rapidly increased, and then hyperextension and rotation complete the 
rupture and the dislocation. The various positions which the limb may 
assume during the continuation of the force, and the consequent changes 
in its relative direction, are manifested in the various forms of dislocation 
which may ensue, and which are, therefore, really secondary or consecu- 
tive displacements. 

If the action is arrested immediately after the first rupture of the 
ligament, the bones may remain in or return to their place as the limb is 
subsequently flexed, and the injury is then a sprain ; if it is arrested 
when the tip of the coronoid process has barely passed under the lowest 
part of the trochlea, the bones may remain in that position, " incom- 
plete dislocation;" or they may be pressed further backward and upward 
by the contraction of the triceps and the dislocation made complete, the 
tip of the coronoid process then lying in the olecranon fossa when the 
limb is extended. 

In a case that came under my observation the dislocation was effected 
by hyperextension and torsion without the aid of the weight of the body 
to press the humerus downward. The patient, in jumping down from 
his wagon, steadied himself by grasping the rail of the seat, and, the 
height being considerable, the wrench was sufficient to dislocate the 
elbow. 

Pathology. — The opportunities to examine recent cases of dislocation 
backward have been few, but the study of older ones and experiment 
upon the cadaver have made our knowledge of the lesions sufficiently 
full. The reports of the autopsies are not very detailed. Sir Astley 
Cooper 1 reports two of them. In one, a compound dislocation, the 
specimen of which is preserved in the museum of St. Thomas's Hospital, 
"■ the coronoid process of the ulna was thrown into the posterior fossa of 
the os humeri, and the olecranon projected on the back part of the elbow 
an inch and a half above its usual position ; the radius was placed behind 
the external condyle. . . . The capsular ligament was torn through, 
anteriorly, to a great extent. The coronary ligament remained entire. 
The biceps muscle was slightly put upon the stretch, and the brachialis 
anticus was excessively stretched. In another case, neither the muscles 
about the joint nor the coronary ligament were torn, but the anterior 
portion of the capsular ligament was extensively lacerated." 

In a specimen presented by Robert 2 to the Societe de Chirurgie, the 
ulna was displaced upward behind the humerus, the radius did not ac- 
company it entirely, but was only partly dislocated backward; the 
external lateral ligament was partly torn; the orbicular ligament was 
ruptured, and a piece of it was interposed in the joint. The brachial 
artery was ruptured. Robert deemed it a dislocation of the ulna alone, 
but Malgaigne and others thought it should be classed as an incomplete 
dislocation of both bones backward. In accordance with Robert's view 

1 Cooper: Disloc. and Fractures, Am. ed., 1844, p. 382. 

2 Kobert : Gaz. des Hopitaux, 1847, p. 272. 



288 



DISLOCATIONS OF THE ELBOW. 



of it, the case will be quoted again in Chapter XX. among dislocations 
of the ulna alone. 

In a case reported by Broca, 1 the coronoid process lay in the olecranon 
fossa, the anterior ligament was torn across midway between its attach- 
ments, the internal lateral ligament was ruptured, and the external 
lateral ligament was detached from the humerus, the annular ligament 
consec^uently remaining intact. The biceps was displaced to the outer 
side of the joint, the brachialis anticus wrapped around the trochlea, and 
torn at several points. The median nerve accompanied the muscle in its 
displacement, but the artery passed directly in front of the humerus 
without changing its direction ; the ulnar nerve was much bruised. 

The detachment of the external lateral ligament from the humerus, as 
in this case, is of much importance if the patient is young, and if the 
dislocation remains long unreduced. In a case of four months' standing 
in a girl eleven years old, which I treated by arthrotomy (vide infra, 
Chapter XXI.), the ligament had apparently been detached in this 
manner, and the periosteum of the posterior surface of the external con- 
dyle stripped up with it by the displaced head of the radius ; a new mass 
of bone continuous with the back of the condyle had formed above 
and behind the head of the radius, making a 
FlG - 7fi - new socket to which it was closely attached 

(Fig. 76). The internal epicondyle had also 
been torn off' and displaced upward, and had re- 
united with the side of the humerus about half 
an inch above its normal position. 

This avulsion of the epitrochlea has been 
noticed in some other cases (see Fractures, p. 
393) ; its occurrence is more easily explained on 
the theory of production of the dislocation by 
lateral flexion of the elbow than on that of 
hyperextension in which only the anterior part 
of the lateral ligament is at first put upon the 
stretch. 

In an autopsy reported by Debruyn and 
quoted by Denuce (loc. cit., pp. 742 and 744) of 
dislocation backward and outward, the epitroch- 
lea was torn off and the brachial artery rup- 
tured. 
The displacement of the bone varies greatly, both in extent and in 
direction. As has been said, the top of the coronoid process may rest 
against the lower and posterior surface of the trochlea, and the radius 
still remain in contact with the under surface of the capitellum by the 
anterior portion of its disk, or it may be entirely dislocated and rest against 
the posterior face of the external condyle, as in a specimen of old dislo- 
cation described by Gely, 2 and now deposited in the Musee Dupuytren. 
The elbow was flexed almost at a right angle and did not appear notice- 
ably deformed. The coronoid process lay in a deep groove on the 




New formation of bone in an 
unreduced dislocation of the el- 
bow backward. 



1 Broca: Bull, de la Soc. Anatomique, 1852, p. 26. 

2 Gel} 7 : quoted by Pingaud, loc. cit., p. 485. 



DISLOCATION OF THE FOREARM BACKWARD. 289 

posterior surface of the trochlea a little nearer its outer than its inner 
border. The head of the radius corresponded by its anterior border 
with the posterior surface of the humerus between the olecranon fossa 
and the epicondyle, and lay in a hollow formed by the excavation of 
the back of the external condyle. The situation of the head of the 
radius at a higher level than the coronoicl process shows that the forearm 
had been rotated about its long axis in the direction of pronation ; in 
addition the wrist was deviated to the outer side. 

AYhen the ulna is more and the radius less displaced the deviation of 
the wrist is to the inner side ; and when both bones are completely dis- 
placed backward deviation of the wrist to either side will incline their 
upper ends to the opposite side, and thus bring them nearer to the internal 
or the external epicondyle respectively. 

If, in the production of the dislocation, the lateral outward flexion is 
more marked than the hyperextension, the capitellum slips along the 
head of the radius to its inner side, and the latter lodges on the outer 
surface of the former just below the epicondyle, while the coronoid process 
rests against the posterior surface of the external condyle, having been 
carried outward by pronation of the forearm. The posterior surface of 
the ulna is directed outward, and the anterior edge of the head of the 
radius rests against the condyle of the humerus. In addition, the long 
axis of the forearm is deviated to the inner' or the outer side ; the internal 
lateral ligament is freely torn. This is the dislocation backivard and 
outivard, classed by some with the outward, by others with the backward 
dislocations, and sometimes misleadingly reported as a pure outward 
dislocation. 

In dislocations backward and inward it is inferred from experiments 
upon the cadaver that the coronoid process rests against the posterior 
surface of the epitrochlea, and the head of the radius by its edge against 
the inner slope of the posterior part of the trochlea. The external lateral 
ligament is torn away from the humerus. The dislocation, according to 
Pingaud, can be produced by hyperextension and supination, but only 
with difficulty and by associating with the movement internal lateral 
flexion, at least sol understand his phrase that '*the effort must be 
directed toward the inner and posterior side of the elbow, and continued 
until the external ligament is entirely torn." Streubel produced it by 
first creating a backward dislocation, and then twisting the forearm 
inward. 

A specimen of entirely exceptional displacement was reported bv 
Henriet; 1 it was obtained from a cadaver in the dissecting-room, without 
history. The general appearance of the limb was that of a backward 
dislocation ; the elbow was stiff' and sliaditlv flexed, the wrist slightly 
pronated. ' The head of the radius had not only passed up with the ulna 
behind the humerus, but had also passed upward in front of the former, 
and was lodged in the great sigmoid cavity between it and the back of 
the humerus, and articulated with the outer half of the anterior surface 
of the olecranon. The ulna was not displaced laterally, but only upward 
and backward. There was strong peripheral fibrous ankylosis ; no sign 

1 Henriet: Bull, de la Soc. Anatomique, 1879, vol. 54, p. 26. 
19 



290 DISLOCATIONS OF THE ELBOW. 

of old fracture. The only change in the shape of the bones was a slight 
secondary accommodative one in the head of the radius. 

Complications. — Fractures of the olecranon, the coronoid process, the 
head, shaft, and lower extremity of the radius, and the epitrochlea have 
been observed in connection with dislocation backward. Fracture of 
the olecranon is effected, presumably, by the pressure of its tip against 
the back of the humerus when the posterior part of the lateral ligaments 
proves stronger than the bone, and a fracture is produced with angular 
deformity and crushing of the posterior portion of the bone at the seat of 
fracture. Malgaigne represents such a case in his Atlas, Plate XX., 
figure 2, in which union has taken place with preservation of the angular 
displacement. He classifies this case as an incomplete dislocation forward 
of both bones, but in estimating his opinion it must be remembered that 
he thought almost all dislocations backward were produced by falls upon 
the elbow, and that he did not accept the theory of production by hyper- 
extension. In a case reported by W. H. Daly 1 of fracture of the olecranon, 
and probably of the coronoid process also, the coexistence of a Colles's 
fracture at the wrist showed plainly that the injury was produced by a 
fall upon the extended hand. In this case, also, there was union with 
angular displacement, but the direction of the angle is not stated. 

Fracture of the coronoid process, not unfrequently diagnosticated clin- 
ically, has been demonstrated by a number of specimens. It is probably 
produced in a dislocation Avhen the momentum of the fall is sufficient to 
force the humerus downward before the hyperextension has quite carried 
the tip of the coronoid process past the trochlea; and Lotzbeck's experi- 
ments indicate that it can also be caused, when the elbow is slightly 
flexed, by the direct impulsion of the lower end of the humerus in a 
direction parallel to that of the long axis of the forearm. Whether or 
not it has ever been so produced upon the living individual is not known. 
As the brachialis anticus is attached, not to the tip of the process, but to 
its anterior face and the adjoining surface of the ulna, the displacement 
is usually slight. The symptoms, diagnosis, and other details have been 
described in Fractures, p. 427. 

Partial fracture of the head of the radius has been observed in a 
number of cases, often associated with fracture of the coronoid process. 
It has been described, with illustrative cases, in Fractures, p. 431. The 
portion broken off is the anterior or inner third, and the fracture is 
effected by the direct pressure of the condyle brought to bear upon the 
periphery of the disk by the displacement backward of the latter. 

One case of fracture of the shaft of the radius and three of fracture of 
its lower end, Colles's fracture, complicating backward dislocation of the 
elbow, are reported in a thesis by Dupuy (These de Paris, 1882, No. 151). 

The dislocation may be made compound by the projection of the 
trochlea through the skin in the fold of the elbow, and the brachial artery, 
and perhaps even the median nerve, may be ruptured. In a case reported 
by Ledderhose, 2 in which the dislocation w T as made compound by a trans- 

1 Daly: Philadelphia Med. and Surg. Reporter, 1880, vol. 43, p. 71. 

2 Ledderhose: Deutsche Zeitschrift fur Chirurgie, vol. 25, p. 238, abst. in Ctlblatt 
fur Chir., 1887, p. 732. 



DISLOCATION OF THE FOREAKM BACKWARD. 



291 



Fig. 



verse wound in the fold of the elbow, the musculo-spiral nerve was torn. 
Five months later the nerve was successfully reunited by suture. 

In another, reported by Ferret, the median nerve, exposed for more 
than three inches in the wound and tightly stretched, sloughed away. 
(See page 37.) 

Symptoms. — The elbow is usually flexed at an angle about midway 
between complete, extension and flexion at a right angle, but it may be 
completely extended, or even hyperextended, as in a case reported by 
Morel-Lavallee, 1 or semiflexed. The limb is shortened, by an inch or 
more, and if viewed from behind the shortening appears to be in the arm, 
because of the elevation of the olecranon, but if viewed from in front in 
the forearm. If a few hours have passed since the injury was received, 
the region of the elbow is occupied by a swelling which may be so great 
as completely to mask the bony points and the characteristic changes in 
outline ; but if this swelling is slight or absent the antero-posterior diam- 
eter of the joint appears increased, and the transverse diameter unchanged. 
The lower part of the triceps curves backward in the median line to the 
end of the olecranon, creating a hollow on either side, in the outer one of 
which may be seen a slight elevation, marking the position of the head of 
the radius. 

The front of the joint appears full, and the forearm just below it is 
broadened by the shortening of the muscles that arise from either con- 
dyle. Sometimes the outline of the trochlea 
can be distinctly felt or even seen, but ordin- 
arily it is masked by the overlying muscles. 

The forearm may take any attitude be- 
tween pronation and supination, for, as 
voluntary rotation is possible, the patient 
places it in the most convenient attitude. The 
axis of the forearm may be deviated to the 
inner or, more frequently, I think, to the 
outer side (Fig. 77). 

Flexion and extension are possible within 
variable, but always narrow, limits and 
painful ; and when flexion is made the 
prominence of the olecranon behind the 
joint is increased. Abnormal lateral mo- 
bility of the joint exists. 

If now the positions of the two epicon- 
dyles and the tuberosity of the olecranon 
can be recognized, it will be seen that the 
latter is displaced backward and upward, 
rising, if the limb is extended, above the 
horizontal line joining the epicondvles, or 
projecting far behind a vertical plane pass- 
ing through these two points if the limb is 
partly flexed. This backward projection of 
the olecranon will be increased bv flexion of the elbow, and at the same 




Dislocation of the elbow backward. 
(From a photograph.) 



Morel-Lavallee, Bull, de la Soc. de Chir., 1856, vol 7, 



292 DISLOCATIONS OF THE ELBOW. 

time it will descend ; while by extension it will be moved to a higher 
level and brought nearer the back of the humerus. 

The head of the radius can be felt, perhaps even seen, under the 
skin below and to the outer side of the olecranon close behind the 
external condyle, and can be recognized by the concavity of its upper 
surface and felt to move under the finger when the wrist is gently rotated. 

On the inner side, if the swelling is not too great, the finger passing 
forward and downward from the tip of the olecranon successively recog- 
nizes the curved inner margin of the great sigmoid cavity, possibly also 
the coronoid process, and the back of the trochlea, and then moving 
around the inner side below the epitrochlea to the front may trace the 
sharp circular margin of the trochlea and recognize its rounded surface 
and groove in front. 

In the so-called " incomplete " cases, those in which the tip of the 
coronoid process has passed only a short distance beyond the centre of 
the under surface of the trochlea, the weight of evidence indicates that 
the elbow is held more nearly at a right angle and that its extension is 
resisted. The description is made difficult by the fact that some authors, 
notably Malgaigne, make the class a large one and include in it, conse- 
quently, many cases which seem properly to belong in the main, or 
" complete," class. The distinction between the two would not be worth 
preserving were it not that reduction may be reasonably hoped for in the 
lesser form after a longer lapse of time than in the other. In the posi- 
tion of flexion of the elbow at or near a right angle, then, the end of the 
olecranon in an " incomplete " dislocation will not project so far as it does 
in a complete one when the limb is placed in the same position, and it 
will be further below the line of the epicondyles than its normal position 
is. Of the only case of the kind that von Pitha saw he says 1 it was " a 
striking picture of a dislocation backward, marked by unusual prominence 
of the olecranon ; " the explanation of this feature must be that in the 
others with which he mentally compared it the limb was less flexed and 
the olecranon consequently less prominent. His diagnosis was made 
upon the spontaneous reduction of the dislocation by a movement of the 
arm before he had time to examine it. 

The diagnosis should be made upon actual recognition by palpation of 
the position of the two epicondyles, the olecranon, and the head of the 
radius. The surgeon should never be satisfied with less than that, and 
if it cannot be obtained he should refuse to make a positive diagnosis. 
No attitude of the limb, no measurements, no apparent changes in its 
diameter, no considerations of abnormal mobility or fixation are sufficient, 
and the surgeon who trusts to them will be only too likely to add to the 
already too long series of limbs crippled in consequence of errors in 
diagnosis. If the swelling is too great to permit the bony prominences 
to be felt, even with the aid of anaesthesia, the examination must be 
postponed until it shall have subsided. 

Of the different fractures that have been mentioned as complications, 
those of the olecranon and epitrochlea are easily recognized by manipu- 
lation ; that of the coronoid process is indicated by easy recurrence of the 

i Pitha and Billroth's Chirurgie, vol. 4, Part 2, p. 70. 



DISLOCATION OF THE FOREARM BACKWARD. 293 

dislocation after its reduction, but if the patient is etherized at the time 
this symptom is by no means characteristic, and furthermore, it is also 
present in those fractures of the internal condyle which are complicated 
by displacement of the fragment and dislocation of the radius backward 
(Fractures, p. 399). Sometimes the tip of the process can be felt as a 
small, hard, movable body in the fold of the elbow and in the line of the 
brachialis anticus. Fracture of the head of the radius can hardly be 
recognized unless the fragment should be so displaced that it can be felt 
on the outer side of the condyle. 

The records of discussions over cases presented to the various learned 
societies show very clearly the great difficulty of making a diagnosis in 
cases that have remained unreduced for any length of time, especially in 
children in whom the injured or stripped up periosteum rapidly forms 
new bone which obscures the original outlines. Much of the uncertainty 
concerning the character and results of reported cases is due to this fact. 

The prognosis is favorable ; reduction in recent cases may be confi- 
dently expected, with complete or almost complete restoration of function. 
In old cases, of more than six weeks' standing, the probability of reduc- 
tion is greatly diminished, although successes have been reported after 
three, five, and even seven months. The greater the displacement 
upward, the arm being only slightly flexed, the less is the probability of 
reduction after the lapse of some time, for the lacerated lateral ligaments 
have then formed new attachments at points so high on the humerus that 
they must be again ruptured before the ulna and radius can be brought 
below the end of the humerus, and in attempting to rupture them by 
flexing the elbow the olecranon is liable to be broken. In addition, the 
sigmoid cavity fills up with fibrous tissue that obliterates its articular 
surface and binds it to the back of the humerus. Furthermore, as the 
injury is most frequent in the young, whose periosteum is active to pro- 
duce bone when irritated or stripped up, obstacles may thus be created 
which cannot safely be overcome except by arthrotomy. In some cases 
of unreduced dislocation the patients have in time obtained a free range 
of motion and a useful limb, but usually the mobility is very slight. In 
a discussion upon the subject in the Societe de Chirurgie (Bulletins, 
1861, p. 103), it was stated as the experience of several of the members 
that, in the older cases at least, it was not uncommon to fail to make com- 
plete reduction of the radius, but that nevertheless the patients recovered 
full use of the joint. Recurrence of the dislocation of the radius alone 
had also been observed. Mason 1 reported such a case in which the recur- 
rence was thought to have taken place during the agitation accompanying 
the recovery from the effects of the ether. 

Even after an early reduction the mobility may be diminished by the 
results of the arthritis, especially in the old and rheumatic, or by new 
formations of bone about the joint which mechanically limit its range of 
motion. 

Compound dislocations usually do well if kept surgically clean and well 
drained ; primary resection, in the absence of special indications, should 
not be done. 

1 Mason : X. Y. Medical Eecord, 1880, vol. 19, p. 398. 



294 DISLOCATIONS OF THE ELBOW. 

Treatment. — Much less attention has been paid in the treatment of 
dislocations backward of the elbow to the obstacles created by the untorn 
ligaments than in those of the shoulder or hip, and methods are in gen- 
eral and successful use that are directly opposed in character to those 
based upon a consideration of such obstacles and upon the principle that 
a dislocated bone should be returned along the route by which it has been 
displaced. The explanation of this success of faulty methods is to be 
found either in an extensive primary laceration of both lateral ligaments 
or in the possible overcoming of the obstacles by increasing the lacera- 
tion. The easy reduction of most dislocations under ether by direct 
pressure in suitable directions upon the projecting ends of the bones is an 
indication that ligamentous obstacles of importance do not exist and that 
the chief opposition is furnished by the muscles spasmodically contracted 
on all sides of the joint, and the inference is too often drawn that, pro- 
vided this opposition is overcome by force or by anaesthesia, the surgeon 
need not particularly concern himself with the attitude of the limb during 
his efforts to reduce. But the success of a faulty method should not 
make us unmindful of its defects ; our work should be done skilfully, as 
well as successfully, and even if our errors will pass undetected and their 
consequences be promptly repaired, we should not lightly commit them. 

Such a generally successful but faulty method is that in which the 
forearm is flexed as nearly as possible to a right angle, drawn directly 
away from the humerus in the direction of the long axis of the latter 
until the tip of the coronoid process is brought below the trochlea and 
then, the traction being relaxed, is moved forward and upward into place. 
Many different methods of effecting this manoeuvre have been employed, 
the one commonly known as Sir Astley Cooper's, although practised in 
exactly the same manner long before his time, in which the surgeon's knee 
is placed in the bend of the elbow, being the most common. Cooper's 
description of it is as follows (loc. cit., p. 382) : " The patient is made to 
sit down upon a chair, and the surgeon, placing his knee on the inner 
side of the elbow-joint, in the bend of the arm, takes hold of the patient's 
wrist, and bends the arm. At the same time he presses on the radius 
and ulna with his knee, so as to separate them from the os humeri, and 
thus the coronoid process is thrown from the posterior fossa of the 
humerus ; and whilst this pressure is supported by the knee, the arm is 
to be forcibly but slowly bent, and the reduction is soon effected. It 
may also be accomplished by placing the arm around the post of a bed, 
and by forcibly bending it while it is thus confined." 

The knee is thus used as the fulcrum of a lever of which the wrist is 
at the end of the long arm, and the olecranon at that of the short one. 
The resistance to be overcome is that of the muscles and of the soft parts 
which bind the ulna and radius to the humerus, and it must be overcome 
to an extent that will allow the ulna to be directly separated from the 
lower border of the humerus to a distance equal to the height of the coro- 
noid process, more than half an inch (Fig. 79); the lateral ligaments, the 
upper fibres of the anconeus, and the stout fascia on the outer side of the 
elbow must all yield to this extent. That they commonly do so is a proof 
of the amount of the laceration and of the force employed. The method 
is faulty because it requires for its accomplishment a maximum of lacera- 



DISLOCATION OF THE FOREARM BACKWARD, 



295 



tion on both sides of the joint which may have, and probably has, been 
escaped in the original injury, and because it requires the simultaneous 
elongation of the muscles of the front and back of the arm. 



Fig. 



Fig. 79. 





Reduction of dislocation of the elbow backward. 
(Hamilton.) 



To show the extent 01 separation of the bones 
necessary in reduction with the elbow at a right 
angle. The dotted line indicates the normal position 
of the ulna. 

It has been employed from very 
early times. A cut copied by Albert 
from Oribasius shows that it was in 
use as early as the fourth century in 
a form in which the application of 
the force w T as as direct and efficient, 
although more complicated, and it 
appears even to have been known to 
Hippocrates. 
Forced flexion, to break up adhesions, may, however, be useful as a 
preliminary to reduction by more suitable methods. 

The specific objection made to this method applies equally to all in 
which reduction is made while the elbow is flexed at a right angle, and 
in a less degree to those in which the joint is partly flexed. In the 
latter the modes of application of the force arj numerous and varied : 
traction by pulleys, by the hand, or by a loop placed above the olecranon, 
and pressure by the thumbs upon the olecranon and head of the radius 
while the fingers are interlocked in front of the lower end of the humerus. 
The more extended the limb the more easily will methods of this kind 
succeed, but they then need to be supplemented by flexion or direct 
coaptation after the coronoid process has been brought sufficiently low. 

A possible obstacle in the way of traction in the extended or slightly 
flexed position is the engagement of the tip of the coronoid process in 
the olecranon fossa of the humerus in such a way that its under surface 
rests directly against the upper posterior portion of the trochlea and 
prevents the ulna from moving bodily in the direction of its long axis. 
It can be disengaged either by hyperextending the elbow or by pressing 
the upper part of the forearm backward and the lower part of the arm 
forward. Except for this possible obstacle traction in complete extension 
meets the indications sufficiently and without needless increase of the 



296 DISLOCATIONS OF THE ELBOW. 

laceration, and the obstacle can be readily overcome, as has just been 
said, by slight hyperextension as suggested by Roser in 1844. He went 
further and proposed that the hyperextension should be increased so as 
not only to free the coronoid process from the fossa but also to bring the 
tip of the olecranon into it, and then, while maintaining it there by the 
pressure of the thumb or hand above it, to flex the limb and thus swing 
the bones into place. 

Traction may be made by the hands of the surgeon himself, or by 
assistants while the surgeon watches the descent of the ulna, frees the 
coronoid process if necessary, and presses the radius and ulna forward 
into place at the proper time ; or it may be made by an India-rubber cord 
or by fastening a weight to the wrist and allowing the arm to hang down. 
A unique case of reduction by traction by^he patient himself was briefly 
reported by Verneuil r 1 the patient, alarmed at the prospect of being 
chloroformed, grasped the bar of the bed with his hand and pulled upon 
it until the bones returned to their place. 

This method, traction upon the fully extended or even hyperextended 
forearm, followed by direct pressure forward of the upper ends of the 
ulna and radius and counter-pressure backward on the lower end of the 
humerus, or simply by flexion, corresponds as nearly to the fundamental 
principle of reduction as is practicable in the usual uncertainty as to the 
exact attitude taken by the limb at the moment of dislocation. 

The pure hyperextension method of Roser seems to be open to the 
charge of neglect of the fact that the overriding of the bones is caused by 
the direct downward pressure of the humerus and should therefore be 
corrected by traction. It maybe true that in many cases hyperextension 
will bring the olecranon back to its fossa, where it will be a centre of 
motion for the movement of flexion which brings the coronoid process 
under the trochlea and the head of the radius under the external con- 
dyle, but if the hyperextension necessary to effect this is in excess of 
that actually made at the moment of dislocation, it will be obtained in 
the reduction only at the price of additional laceration, and is therefore 
open to the same objection that was urged against the method by " dis- 
traction." The objection would lie especially, I think, in cases in which 
the displacement is outward as well as backward, and in which there is 
reason to think that the external lateral ligament is not extensively torn, 
cases, in a word, in which outward lateral flexion has predominated over 
hyperextension in producing the displacement. In such cases traction 
associated with gradual return of the forearm to the axial line and with 
rotation of the forearm or ulna to lift the tip of the coronoid past the 
outer edge of the trochlea would meet the indications. 

In all cases of doubt or difficulty anaesthesia should be used; and, as 
a general rule, whenever a lateral displacement is associated with the 
backward one the bones should be pressed sideways into line before they 
are drawn downward. 

When the lateral element of the displacement is very marked and it 
is probable that the primary dislocation was directly outward and has 
been followed by a consecutive displacement backward, anaesthesia should 

1 Verneuil : Bull, de la Sue. de Chir., 1861, p. 495. 



DISLOCATION OF THE FOREARM BACKWARD. 297 

not be omitted, and after full relaxation has been obtained the first attempt 
should be to move the olecranon and head of the radius to the radial side 
of the humerus, to transform the dislocation into a pure outward one. 
By so doing the principle of replacing the bones by the route along 
which they have been displaced is followed, and the risk of engaging 
the tendon of the biceps behind the external condyle is avoided. (See 
also the following section.) If the attempt, cautiously made, does not 
succeed, the surgeon should next seek to change the displacement into a 
pure backward one and reduce as before described. 

If some time has elapsed since the accident, more than ten or fifteen 
days, it may be desirable to break up such adhesions as have formed by 
flexion, extension, and lateral flexion, but it must be borne in mind that 
forced flexion always carries the risk of fracturing the olecranon. This 
is sometimes intentionally done to facilitate reduction in old cases ; it is 
of course followed by more or less loss of the power of active extension. 

Fracture of the coronoid process requires no special treatment ; 
apparently the fragment is seldom, if ever, much displaced, for it retains 
its connection with the capsule and, after reduction, is steadied between 
the lower end of the humerus and the tendon of the brachialis anticus. 
The special indication arising from it is to guard against a recurrence of 
the dislocation, which is best done by keeping the elbow flexed at or even 
within a right angle. A posterior moulded splint is an additional safe- 
guard. 

Fracture of the olecranon requires the special treatment proper to that 
injury, but as the extended position of the joint, which is most favorable 
for the prompt and close repair of the fracture, exposes to a partial or 
even complete recurrence of the dislocation it must be avoided until after 
the rupture of the lateral ligaments has been in great part repaired. If, 
in the flexed position, the olecranon is separated from the ulna it should 
be drawn down and held in contact by adhesive plaster, rubber cords, or 
metal hooks. I prefer the latter in most cases, but they are not gener- 
ally acceptable to patients. The contraindications to their use are much 
bruising and swelling of the region, and such local or general conditions 
as predispose to suppuration. 

Fracture of the head of the radius requires prolonged rest of the joint, 
with a view to reunion if the fragment remains in place. If displaced 
and readily accessible, as in the case reported in Fractures, page 433, 
it may be removed, but such removal should not, in my opinion, be 
undertaken until after the lapse of at least a fortnight after the accident, 
at a time, in other words, when the primary laceration of the soft parts 
has been recovered from. Possibly it might be safely left until its pres- 
ence in its abnormal position has proved disadvantageous. Possibly, 
also, it might prove desirable in case of non-union or faulty union to 
remove a fragment that has remained within the joint; the only cases 
in which this has thus far been done have been cases of unreduced dislo- 
cation of the radius alone. If the fragment should remain on the inner 
side of the joint, between the radius and ulna, it would be most easily 
reached through an anterior incision, in making which, however, special 
care would have to be taken to avoid injury to the musculo-spiral nerve 
and its two branches, the radial and posterior interosseous. 



298 DISLOCATIONS OF THE ELBOW. 

Fracture of the epitrochlea requires that the elbow should be kept well 
flexed, to relax the muscles of the forearm that arise from this prominence. 

If the dislocation is compound, but without laceration of the soft parts 
so extensive as to make amputation unavoidable, the parts must be thor- 
oughly cleansed- and replaced, efficient drainage provided through the 
wound and through counter-openings at the back of the joint, and the 
limb immobilized in a plaster splint. Some, perhaps extensive, suppura- 
tion is probable in the soft parts, but the joint is likely to escape so far 
as to preserve a fair amount of motion. As I write, there is in my 
service at Bellevue Hospital a flabby, alcoholic, elderly woman who is 
convalescing satisfactorily from such an injury with fair mobility of the 
joint. Even if the brachial artery is torn the limb may still be saved ; 
and although the additional complication of rupture of the median nerve 
has been thought to make amputation necessary, I think a different view 
would now be taken and the attempt would be made to reunite its ends. 
Fortunately both complications, especially the latter, are very rare. 

If the swelling and bruising are such that reduction cannot be made, 
or, if made, would create such tension as to endanger the vitality of the 
limb the end of the humerus should be excised. The results of excision of 
the elbow for all causes are, as a rule, very good, the worst being those in 
which the connection of the bone remains very loose. Ankylosis is to be 
preferred to a "flail-joint," particularly if the patient is a laboring man. 
An arm, the elbow of which is stiff, is capable of rendering much useful 
service. 

After-treatment. — In uncomplicated cases it is necessary only to retain 
the limb in a sling for two or three weeks, or until such time as the 
dependent position does not cause pain. Passive motion, to prevent 
ankylosis, is not necessary and is actually harmful during the first fort- 
night if it causes pain. The limb may safely be immobilized until the 
injury to the capsule and ligaments has been repaired. It will be more 
or less stiff when first taken out of the dressings, but complete restoration 
of its functions may be confidently expected under daily use. Exceptions 
to this complete recovery are sometimes found in the old and rheumatic, 
in complicated cases, and in the young if the periosteum has been exten- 
sively stripped up. In the first class, the old and rheumatic, gentle 
passive motion strictly confined within the limits beyond which persistent 
pain and tenderness are caused, may be of service to diminish the subse- 
quent stiffness and hasten its disappearance, and in all it may be useful 
to change every day or two the angle at which the limb is immobilized. 

Lateral Dislocations of the Forearm. 

Both bones of the forearm may be together dislocated to the inner or 
to the outer side, and the dislocation may be complete or incomplete. In 
the incomplete form, in the sense in which the term has been generally, 
and will here be, used, one of the two bones still remains below or in 
front of the lower end of the humerus, although it may have entirely left 
its own corresponding articular surface ; thus, in the incomplete outward 
dislocation the sigmoid cavity of the ulna lies below and embraces the 
external condyle, and its inner slope may still correspond to the outer 



INCOMPLETE LATERAL DISLOCATIONS. 299 

part of the trochlea or may have passed entirely to its outer side. In the 
complete outward dislocation, on the other hand, the sigmoid cavity of 
the ulna is turned toward (pronation) and embraces the outer side of the 
external condyle or the supinator ridge, and the head of the radius lies 
nearer the median line in front of the humerus. Much confusion has arisen 
from the use of the terms outward and inward dislocation to include also 
the outward and backward and the inward and backward respectively, 
both in text-books and in the reports of cases in the journals. The terms 
will be here restricted to those cases in which the primary dislocation is 
directly outward or inward, the coronoid process remaining in front of, and 
the olecranon behind, the transverse longitudinal plane of the humerus. 
In some cases of outward and backward dislocation the question may 
arise whether the position in which the bones are found is not the result 
of a consecutive displacement following a primary outward displacement. 
I believe such consecutive displacements to be very rare, and that the 
great majority of backward and outward dislocations belong, by their 
essential features, among the backward ones with which I have above 
described them. 

In a dislocation backward and inward this question does not arise, for 
a complete inward dislocation has never yet been reported ; but the con- 
fusion is, nevertheless, equally great, for the epithet tw backward and 
inward" has been indiscriminately applied to all displacements toward the 
inner side, including, as Trelat pointed out, three distinct varieties : 1st, 
dislocations of both bones inward ; 2d, dislocations of both bones back- 
ward and inward, and 3d, dislocations backward of the ulna alone. 

Incomplete Lateral Dislocations. 

Doubtless it must be attributed to this confusion in the use of terms 
that the frequency of incomplete dislocations to the outer or the inner 
side passed unnoticed until 1863, when a German surgeon, Halm, who 
had practised for more than forty years at Stuttgard, published a paper 1 
upon the subject in which he stated he had treated 21 cases of this injury 
in thirty years, nearly as many as those of dislocation backward observed 
during the same period; of these, 18 were in children, 3 in adults ; 12 
of the former and 2 of the latter were in males, and in all but one the 
dislocation was inward. The statement, which was supported in many 
points by the observations of the reviewer of the paper, Streubel, at once 
attracted attention and has been confirmed and accepted by subsequent 
writers ; the principal contributions to the subject have been made by 
Hueter, 2 Nicoladoni, 3 and Sprengel. 4 Hueter described 6 specimens of 
outward dislocation obtained by resection and 3 cases observed clinically ; 
Nicoladoni found 4 incomplete outward dislocations in 16 dislocations of 
the elbow observed in four and a half years ; and Sprengel reported that 
the records of the Halle clinic for the years 1873-1879 contained 32 
cases, of which 20 were inward and 12 outward. An important feature 

1 Hahn : Schmidt's Jahrbuch, vol. 119, p. 74, and vol. 120, p. 88. 

2 Hueter: Arch, fur klin. Chirurgie, 1867, vol. 8, p. 153, and vol. 9, p. 935. 

3 Nicoladoni: Wiener med, Wochenschrift, 1876, pp. 570, 599, 640, and 670. 

4 Sprengel: Centralblatt fur Chir., 1880, n. 129. 



300 DISLOCATIONS OF THE ELBOW. 

of the last communication is that 15 of the 32 (11 inward, 4 outward) 
were old cases and in only 1 of them could reduction be obtained. 
Although it is not so stated, it is probable that in many of them an error 
in diagnosis had been committed; Hahn says the injury is frequently 
mistaken for fracture of the lower end of the humerus. In a case seven 
months old reported by Sprengel the injury had been pronounced by a 
well-known London surgeon, who gave the patient a written opinion, an 
intercondyloid fracture of the humerus, and he added that there was no 
trace of the dislocation said to have existed; Sprengel excised the joint 
and demonstrated the dislocation. In view of these facts, of the possible 
errors in diagnosis, of the frequency of the injury in children, it has 
seemed best to treat of the two varieties under a single head, as incom- 
plete lateral dislocations. 

The cause is usually a fall udou the outstretched hand ; exceptional 
causes are falls upon the inner side of the elbow and blows received upon 
the forearm. The interlocking of the central ridge of the sigmoid cavity 
in the groove of the trochlea is such that direct lateral displacement 
without preliminary separation of the articular surfaces, or without their 
fracture, is impossible, and it is highly probable that the dislocation is 
produced by lateral flexion outward of the completely extended forearm, 
or possibly by its equivalent pronation when partly flexed — that is, the 
ulna is moved downward (in the prolongation of the transverse longitu- 
dinal plane of the humerus) and outward, turning upon the humero-radial 
articulation as a centre, and thus the internal lateral ligament is rup- 
tured. The joint is thus opened upon its inner side, the sigmoid cavity 
and trochlea separated from each other, and only the radius and capi- 
tellum remain in contact at their outer borders. If now the capitellum 
slips inward along the upper surface of the radius an incomplete outward 
dislocation is produced ; if, on the contrary, the radius slips inward along 
the capitellum an ■ incomplete inward dislocation is the result. This 
mechanism can be reproduced upon the cadaver, but it must be admitted 
that the explanation is theoretical ; accurate clinical observation, for 
reasons often above referred to, are not obtainable, and it is impossible 
to reproduce all the factors upon the cadaver. 

It is thought by some that the mechanism is the same in its first part 
as that of backward dislocation, and that, the force being less, the bones 
of the forearm are not displaced so far that the coronoid process clears 
the trochlea, but that on the cessation of the violence and the straight- 
ening of the limb the point of this process finds itself not only in front 
of the trochlea, but also on the outer or inner side of its outer or inner 
margin, against which it is so locked that on the straightening of the 
limb the bones are moved sideways to come into line with its new position. 
The theory finds some support in the results of cadaveric experimentation, 
in which the sigmoid cavity is sometimes found to embrace the lower end 
of the humerus obliquely, and also in the fact made known by Streubel, 
and verified by others, that the outward dislocation can be produced by 
hyperextension if it is accompanied by forcible supination and followed 
by flexion. 



INCOMPLETE INWARD DISLOCATIONS 



301 



A. Incomplete imuard dislocations. 

Pathology. — The autopsies and direct examinations that have been 
reported and are available to show the new relations of the bones are few 
in number. There are two autopsies reported by Broca 1 and Jolivet, 2 
and the case above referred to in which Sprengel excised the joint seven 
months after the injury was received. In the latter the head of the radius 
rested against the lateral part of the trochlea, and the ulna was displaced 
so far inward that nearly half of the sigmoid cavity projected free beyond 
the trochlea ; upon this free part, and united with it, lay the fractured 
tip of the epitrochlea. There was close fibrous union between the opposing 
articular surfaces. 

Broca's case was a much older one ; the specimen and a plaster cast 
of the limb are preserved in the Musee Dupuytren, the latter is repre- 
sented in Fig. 80. It differs from 

the usual clinical form in the very Fig. 80 - 

marked displacement downward 
and backward of the head of the 
radius. The neAv joint permitted 
full flexion and almost complete 
extension, and the axis of the 
forearm was inclined downward 
and outward 30° from the prolon- 
gation of that of the humerus. 
The distance between the promi- 
nences formed by the tip of the 
olecranon and the head of the 
radius was six centimetres. There 
remained no trace of the lateral 
and annular ligaments ; a fibrous 
capsule of new formation con- 
nected the bones with one another. 
Broca says there was no sign of 
former fracture, but Denuce (loc. cit., p. 765), who appears to have 
examined the specimen, says the external condyle appears to have been 
broken off and displaced forward. The sigmoid cavity embraces the 
epitrochlea, and forms a new articulation with it ; the radius lies below 
the inner part of the trochlea and projects notably behind it. 

Jolivet's specimen was obtained by amputation eighteen months after 
the injury. The patient was a man thirty-six years old, and the dislo- 
cation was caused by a mine explosion. The elbow was flexed, the fore- 
arm semipronated, and there was very slight mobility. The olecranon, 
displaced inward, embraced the epitrochlea by its sigmoid cavity and 
even projected a little beyond its inner side. The olecranon fossa was 
empty ; the anterior and inner part of the head of the radius rested upon 
the outer articular half of the trochlea, the sharp inner border of the latter 
lying like a wedge between the radius and ulna. The coronoid process 

1 Broca: Bull, de la Soc. Anatomique, 1849, p. 272. 

2 Jolivet : Bull, de la Soc. Anatomique, 1865, p. 184. 




Old incomplete dislocation inward ; Broca's cai 
epitrochlea ; c b, olecranon ; d, head of radius. 

NXJCt.) 



(De- 



302 DISLOCATIONS OF THE ELBOW. 

lay in a new groove formed at the expense of the epitrochlea and the 
adjoining side of the trochlea. The posterior edge of the head of the 
radius could be felt as a prominence at the back of the joint. 

Both lateral ligaments are necessarily torn, and probably the anterior 
one likewise ; the annular ligament may perhaps resist, though it must 
at least be put upon the stretch by the interposition of the inner anterior 
edge of the trochlea between the head of the radius and the coronoid 
process. The clinical features indicate that the head of the radius lies 
rather below than directly in front of the trochlea, even in flexion of the 
elbow at a right angle. 

Symptoms. — The elbow is slightly flexed, less so, Hahn says, than is 
common in backward dislocations, and is pronated. The axis of the fore- 
arm is parallel with that of the arm and a little to its inner side. The 
prominence of the epitrochlea is lost, that of the outer epicondyle increased ; 
the diameters of the elbow do not seem to be increased, nor the limb to 
be shortened. Flexion and extension are quite free, and painless within 
certain limits. 

On palpation, the olecranon can be recognized immediately behind the 
position of the epitrochlea and extending so far to the inner side as to 
mask this prominence completely ; the triceps shows as a rather prominent 
elevation running downward and inward. The external epicondyle can 
be plainly felt, and the absence of the head of the radius from its normal 
position recognized ; the latter can sometimes be felt below the empty 
olecranon fossa. Soft cartilaginous crepitation is felt on making passive 
motion. 

Treatment. — Reduction in recent cases appears to be easy by traction 
in the extended position and direct pressure upon the side of the ulna. 
Theoretically, outward lateral flexion combined with moderate traction 
and followed by direct pressure ought to effect reduction readily and 
without risk of fracture, especially if anaesthesia is employed. 

Sprengel's statistics, quoted above, indicate that reduction is very diffi- 
cult in old cases ; out of 11 only 1 was reduced, but the length of time 
that had elapsed is not given except in the one case that was reduced, 
eight weeks. Pingaud recommends that the dislocation should be trans- 
formed into one that is backward and inward, and then reduced. 

Broca's specimen and two of Sprengel's cases show that the joint, 
even if reduction is not made, may have a free range of motion and the 
limb may be useful ; in his other cases Sprengel's attempts to increase 
the range of motion failed more or less completely. 

B. Incomplete outward dislocation. 

This form, although apparently somewhat less frequent than the pre- 
ceding, has been more fully studied. Its causes and mechanism have 
been described above. 

Pathology. — Fig. 81 represents a specimen from an old case 
presented to the Societe Anatomique by Poumet ; it is described by 
Malgaigne, Denuce, and Pingaud as one of the only two cases known, 
the other, Pinel's, being very similar. The list has since been increased 
by the five specimens obtained by Hueter by resection, by Hutchinson's 



INCOMPLETE OUTWARD DISLOCATION. 



303 



Fig 




Incomplete outward dislocation. 
(Poximet.) 



autopsy, and by Sprengel's case in which the dislocation became com- 
pound. The last two are the only examples of the condition in the recent 
state of which I have knowledge, and the infor- 
mation furnished by the last one relates only to 
the position of the bones. 

Sprengel's patient (loc. cit.) was a girl seven 
years old ; the injury was caused by a fall, was 
supposed to be a fracture, and was treated by 
immobilization in a gypsum dressing. Five 
weeks later she came under Sprengel's observa- 
tion. On removal of the dressing a slough an 
inch in diameter was found to have formed, and 
through the opening created by it the internal 
condyle presented. The head of the radius 
could be distinctly felt below the external con- 
dyle, the ulna was displaced outward so that the 
outer half of the sigmoid cavity embraced the 
capitellum ; the forearm was pronated and fixed 
in a position midway between flexion and ex- 
tension. Forcible abduction was made as a pre- 
liminary to reduction, and the opening of the 
slough was thereby so enlarged that the position 
of the bones as described was verified by direct 
inspection. The child made a good recovery. 

Hutchinson's 1 specimen was of a recent case, the patient having died 
of associated injuries. The dislocation had been reduced during life ; 
on the table it could be easily reproduced, and the bones could be dislo- 
cated to either the outer or the inner side. The sigmoid notch rested 
against the external condyle and the head of the radius projected beyond 
the latter. The lateral ligaments were completely torn, and there were 
several rents in the anterior one ; the orbicular ligament was entire, but 
much stretched. Small portions of cartilage had been broken from the 
articular surfaces of all three bones. 

Poumet's specimen (Fig. 81) is thus described by Pingaud (loc. cit., 
page 526). " The ulna, carried directly outward, has completely left the 
trochlea, which projects on the inner side and contains in its groove a 
large sesamoid bone [evidently the broken-off epitrochlea, vide infra]. 
The external articular slope of the sigmoid cavity is in relation with the 
capitellum, which is notably hypertrophied, as is also the epicondyle, 
while the trochlea and epitrochlea are atrophied. The radius, displaced 
outward and especially forward, is in indirect relations with the epicondyle 
and the remainder of the condyle, outside of which is a small sesamoid 
bone which completes the surface of articulation on this side. It results 
from these anatomical relations that the forearm is in slight flexion with 
rotation inward ; the ligaments, especially the lateral ones, are in great 
part ruptured. 

Hueter's six specimens all showed the same displacement, and the 
epitrochlea torn off and lodged in the groove of the trochlea. The same 



1 Hutchinson : Med. Times and Gazette, 1866, i. p. 410. 



304 DISLOCATIONS OF THE ELBOW. 

avulsion of the epitrochlea has been observed clinically in five other cases, 
Albert and von Dumreicher 1 each one, and Hueter 2 three, in two of 
which it prevented reduction, and in the others made reduction very diffi- 
cult. In two other cases also observed clinically by Nicoladoni, in 
which reduction was not attempted because of the length of time that 
had passed since the injury was received, fourteen and five months 
respectively, the epitrochlea was broken off ; in one it could not be found, 
in the other it lay below and near the sharp inner edge of the trochlea. 

The complication appears to be much more common in children than 
in adults ; of the 13 cases here quoted 7 were young, in 4 the age is not 
given, and 2 were adults when the joints were excised, 

Nicolacloni, after experimenting upon the cadaver, reached the opinion, 
which seems to be correct, that this avulsion of the epitrochlea is effected 
through the attached flexor muscles and not through the internal lateral 
ligament which is inserted only upon its base. 

His experiments show that the internal lateral ligament is always 
ruptured, usually close to its insertion at the base of the epitrochlea, but 
sometimes nearer to or at its attachment to the ulna. The rupture 
extends backward along the margin of the sigmoid cavity to the tip of 
the olecranon, and in front through the anterior ligament to the outer 
side of the coronoid process. The external lateral and the annular liga- 
ments are untorn. The clinical cases indicate, however, that the annular 
ligament also is sometimes ruptured. 

Symptoms. — The elbow is somewhat flexed, the angle varying in the 
different cases, the forearm pronated. The axis of the forearm is some- 
times parallel with and external to that of the arm, sometimes adducted. 
The prominence of the internal condyle is increased, even if the 
epitrochlea is broken off, and the skin is tightly stretched over it. The 
transverse diameter of the elbow is increased by the projection of the 
muscles and the head of the radius on the outer side. Flexion and 
extension are painful and restricted. In the reported cases no mention 
is made of lateral mobility, and it seems probable that if present it is 
only slight. 

On palpation the epitrochlea, unless broken off, is very readily felt ; 
if it is broken off, the inner side and edge of the trochlea can be plainly 
traced, and the epitrochlea may perhaps be recognized as a movable body 
below it, or it may have been drawn past the edge of the trochlea into 
its groove where it cannot be felt. 

On the outer side the head of the radius projects in a line with the 
anterior or under surface of the condyle, according as the elbow is more 
or less flexed. The olecranon is more prominent than normal, because 
it is lifted out of its fossa and lies against the back of the more prominent 
external condyle ; it is distant from the epitrochlea about two inches. 
The triceps appears as a prominent cord directed downward and outward 
to the olecranon. The external epicondyle may be felt hj pressing 
the finger firmly in above the head of the radius and behind the promi- 
nence formed by the extensor muscles of the hand. 

1 Nicoladoni : Loc. cit, p. 571. 

2 Hueter: Arch, fiir klin. Chir., vol. 9, p. 935. 



INCOMPLETE OUTWARD DISLOCATION. 805 

According to Pingaud, the forearm is so pronated that the posterior 
surface of the ulna looks outward, and the head of the radius lies in front 
of the capitellum instead of being displaced outwardly. Such cases 
belong, I think, to the class of dislocations of the ulna alone. 

Treatment. — The first indication of treatment is to lift the central 
ridge of the sigmoid cavity and the coronoid process out of the groove 
between the capitellum and the trochlea, or, in other words, to separate 
this portion of the ulna sufficiently from the under surface of the humerus 
to allow it to be pushed inward past the projecting outer border of the 
trochlea. This may be effected by hyperextension, or by outward lateral 
flexion if the head of the radius still rests against the under surface of 
the humerus so as to form a fulcrum or centre for the movement. 

If hyperextension is made, the movement takes place about the tip of 
the olecranon as a centre, where it rests against the back of the humerus, 
and the coronoid process is carried downward away from the humerus as 
well as backward, and when the separation is sufficient direct pressure 
with the thumbs upon the head of the radius will force the bones into 
place, or rotation of the ulna inward will carry the tip of the coronoid 
process past the margin of the trochlea into the groove. Nicoladoni 
suggests that in the latter manoeuvre an assistant should press with his 
thumb upon the back of the olecranon to prevent the production of a 
backward dislocation. 

Outward lateral flexion should be aided by traction upon the extended 
or slightly flexed forearm, by which the articular surfaces will be sepa- 
rated as far as the untorn ligaments will permit, then pressure by the 
thumb upon the head of the radius, associated, of course, with counter- 
pressure on the inner side of the humerus, will force the inner ends of 
the bones back into line, and the straightening of the limb completes the 
reduction. 

If the annular ligament is torn, its outer portion and the adjoining 
part of the external lateral ligament may be interposed between the radius 
and the humerus and oppose the return of the former ; under such circum- 
stances the ulna can still be reduced, but the lateral pressure to effect 
this must be made upon the olecranon instead of the radius, and then by 
pronating and adducting the forearm the radius is drawn past the obstacle 
into place. The suggestion of the existence of this obstacle and of the 
means by which it may be avoided rests entirely upon experiments on the 
cadaver. I do not know that it has ever been encountered and thus 
overcome in practice. 

The complication of avulsion of the epitrochlea and its lodgement in the 
groove of the trochlea seriously increases the difficulty of reduction. As 
above stated, in two of the five recent cases in which it was recognized 
i eduction failed. The reason of the failure is that the displacement of 
the fragment from the groove by the returning ulna is prevented by the 
sharply inclined inner slope of the trochlea and by the pressure of the 
overlying muscles and fascia. The fragment needs to be drawn down- 
ward as well as pushed inward. Albert succeeded by flexing the forearm 
at a right angle, and then drawing it forcibly away from the humerus in 
the direction of the long axis of the latter by means of a cord passed 
across its anterior surface close to the elbow. The same method, when 

20 



306 DISLOCATIONS OF THE ELBOW. 

employed by von Pumreicher, failed, as did also forcible outward lateral 
flexion and traction, although carried so far as to threaten rupture of the 
skin on the inner side of the joint. 

Possibly the transformation of the dislocation into the direct backward 
form, or backward and inward, would remove the fragment from the 
groove, and make reduction possible. It would involve additional lacer- 
ation of the soft parts, it might even be advisable to divide the external 
lateral ligament subcutaneously, but those disadvantages would be less 
than the crippling due to an unreduced dislocation. Possibly too, it 
would be practicable to draw the fragment downward out of the way by 
a sharp hook passed through the skin. 

Complete Dislocations Outward. 

These dislocations, of which the first observation was reported by 
Dupuytren in 1807, although the form had been described by Petit nearly 
one hundred years before, were apparently so rare that Malgaigne could 
collect only ten reported cases. Of late, reports have so multiplied that, 
excluding irregular cases, and those of which the description is not suffi- 
ciently detailed, and those which seem more properly to belong among 
the dislocations backward and outward, the number of those available for 
study and generalization is about twenty-five. 1 

In most of the cases the mechanism of production cannot be determined, 
but the histories of a few are sufficiently complete to show that the cause 
may be a fall upon the outstretched palm or upon the elbow, or a blow 
received upon the inner side of the forearm. Hatry's case is a clear 
example of the first, the patient stumbled and fell forward upon his hand ; 
von Pitha's patient, who fell while her hands were in her muff, is an 
example of the second ; and Mears's patient, who was struck upon the 
inner and upper part of the forearm by a revolving piece of wood while 
the elbow was partly flexed in an effort to draw down some object from 
above his head, is an example of the third. The mechanism in a fall 
upon the hand is doubtless the same as that in incomplete dislocation 

1 The bibliography, excluding doubtful cases is as follows: Dupuytren, Legons 
orales, vol. 1, p. 131 ; Bouley, Bull, de la Soc. Anatomique, 1837, p. 101 ; Nelaton, 
Pathol, chirurgicale, vol. 2, p. 391 ; Neilson, Lancet, 1844, ii. p. 559; Robert, Gaz. 
des Hopitaux, 1849, p. 180; Soule, Gaz. Medicale, 1849, p. 717; Verneuil and Tri- 
quet, Gaz. Medicale, 1851 [?] ; Piogey and Dubrueil, Gaz. des Hopitaux, 1851, p. 
30; Denuce, These de Paris, 1853 ; Flaubert, idem ; Puech, Gaz. des Hopitaux, 1859, 
p. 434; Sistach, Bull, de la Soc. de Chirurgie, 1866, p 520; Varick, N. Y. Med. 
Record, 1867, vol. 2, p. 387; Andrews, idem, 1875, p. 720; Von Pitha, Pitha and 
Billroth's Chirurgie, vol. 4, abt. 2, B, p. 71, 4 cases; Hatry, Lyon Medical, 1876 
vol. 18, p. 13; Wylie, in Hamilton's Fracts. and Dis., p. 698; Bertin, Union Med. 
1876, p. 609 ; Osborne, N. Y. Hosp. Gaz., 1879, p. 613 ; Mason, N. Y. Med. Record 
1880, vol. 17, p. 397, 2 cases ; Towne, idem, p. 525 ; Ekwurzel, Phil. Med. and Surg 
Reporter, 1881, vol. 45, p. 38; Mears, Phil. Med. Times, 1880-1, vol. 11, p. 89 
Johnson, Trans. Mo. State Med. Assoc, 1880, p. 33 ; Battiscombe, Lancet, 1886, ii. p 
397. I have not been able to verify the reference for Dupuytren's and Verneuil'; 
cases. The Gazette Medicale for 1851 does not contain the latter ; in the Gazette 
des Hopitaux, 1851, pp. 93 and 201, is an article by Verneuil and Triquet which 
contains a case of incomplete outward dislocation. 



COMPLETE DISLOCATIONS OUTWARD. 307 

outward produced in the same manner — that is, outward lateral flexion 
is produced ; the internal lateral ligament is ruptured, and then the 
bones are displaced laterally past one another by the continued action of 
the weight of the body. In one of von Pitha's cases this lateral flexion 
was observed by the mother of the patient, a boy, six years old, who saw 
the elbow bend as he fell from a tree upon his outstretched hand. 

Pathology. — The only recorded autopsy is the one reported by Bouley, 
a compound dislocation with fracture of the external condyle produced 
by a fall upon the elbow from a height of twenty-eight feet ; amputation 
was refused, and the patient died on the twenty-fifth day. The lateral 
ligaments of the elbow were entirely ruptured ; both bones of the forearm 
were placed externally to the lower extremity of the humerus, and the 
ulnar nerve was lacerated at the level of the trochlea. Our knowledge 
of the pathology of the dislocation is mainly derived, therefore, from 
experiment and from clinical observation. Disregarding one or two 
exceptional forms, the cases may be grouped in three classes according 
to the character of the displacement, but in some the account is not suffi- 
ciently complete to determine to which class the case should belong. 

In one, apparently the least frequent, the displacement is directly 
outward and a little upward, so that the inner edge of the sigmoid cavity 
rests against the outer surface of the external condyle, the elbow being 
partly flexed, with the olecranon behind and the coronoid process in 
front of the epicondyle. The radius preserves its relations with the ulna 
and is situated still further to the outer side, or is carried to a somewhat 
higher level by pronation of the forearm. This involves complete rup- 
ture of the lateral and anterior ligaments. In Neilson's case it was 
thought the external condyle was broken ; the olecranon was three inches 
above its usual position. 

In the second class the forearm is pronated as well as flexed, and this 
pronation is effected by rotation about the long axis of the ulna, so that 
the head of the radius lies above, or is even carried to the inner side of 
the ulna. The great sigmoid cavity embraces the outer surface of the 
external condyle, the tip of the olecranon lying behind the condyle and 
that of the coronoid process in front of it. The anterior surface of the 
ulna looks inward. The head of the radius lies above its normal position, 
in front of the humerus, and possibly still in contact with the upper part 
of the articular surface of the capitellum. Study of the skeleton indicates 
that this form can be easily produced from an incomplete outward dislo- 
cation by pronation of the limb ; it is, I think, the most common of the 
three classes, and it seems possible that the external lateral ligament may 
be preserved untorn. Denuce has given it the name of sub-epicondylar , 
in distinction from the following, third, class, which he terms supra- 
epicondylar. He thinks the distinction is an important one and that the 
difference depends upon the rupture or the integrity of the attachment of 
the muscles upon the epicondyle. 

In the third class the ulna and radius, pronated and flexed, are carried 
higher up along the outer border of the humerus, two inches in Osborne's 
case. The sigmoid cavity may embrace the supinator ridge, and the 
radius still lie in front of the humerus, or both bones may be displaced 



308 DISLOCATIONS OF THE ELBOW. 

also backward so that the coronoid process and the articular surface of the 
radius are posterior to the ridge. 

It is noteworthy that in none of the cases is fracture of the epitrochlea 
mentioned ; in one or two it is said that the epitrochlear muscles were 
torn away at their insertion. 

Two cases, in which an additional consecutive displacement had followed 
by which both bones were brought around in front of the humerus and 
pronated so far that their posterior surfaces were directed forward, were 
reported by Cloquet (quoted by Malgaigne, loc. cit., p. 616) and Maison- 
neuve. 1 The latter's patient was a woman who had fallen out of bed 
upon her elbow, and who was so thin that the position of the bones could 
be accurately determined; the lower end of the humerus projected promi- 
nently behind and was there covered only by the skin, while the triceps 
ran forward and outward over the epicondyle. The ulna was completely 
turned around so that its posterior surface looked forward and the sigmoid 
cavity lay against the front of the trochlea. The head of the radius could 
not be felt. The limb was slightly flexed and greatly pronated. Reduc- 
tion was effected by moving the olecranon outward and backward around 
the external condyle to the back of the humerus, and then reducing in 
the usual manner the backward dislocation thus produced. 

A case of Velpeau's, briefly reported in the Bulletin de Therapeutique, 
1848, vol. 35, p. 128, as a forward dislocation and quoted by several 
authors, is an incomplete dislocation inward. The above-mentioned 
report is apparently unofficial and is full of errors and contradictions. 
The case is reported in detail by Verneuil and Triquet, Gazette des 
Hdpitaux, 1851, p. 94; it is that of a woman, twenty-two years old, who 
had been run over by a wagon. 

Symptoms. — Of the first variety, dislocation directly outward without 
rotation of the forearm, Puech's case may be taken as a type. The 
patient was a man forty-one years old, and the injury was caused by a 
fall from a height of about two feet, the elbow striking against some 
stones. The forearm was extended and supinated ; it could be passively 
flexed nearly to a right angle but could not be pronated ; its axis lay 
entirely to the outside of the humerus, and the transverse diameter of the 
elbow was nearly doubled. Tracing the bones with the finger behind, 
from the epitrochlea outward, the surgeon recognized all the points of 
the lower end of the humerus, then the olecranon well above and to the 
outer side of the condyle, and then the head of the radius lower than the 
olecranon but still above the lower line of the humerus. In other similar 
cases extreme mobility of the joint is mentioned ; as if the two segments 
of the limb were very loosely attached to each other. 

In the second variety, " sub-epic ondylar^ the axis of the forearm 
appears generally to be inclined downward and inward (adduction) ; 
flexion at, or even within (Pitha), a right angle is common ; semi-, or 
full, pronation. The transverse diameter of the elbow is increased, but 
not so much as in the preceding variety. The supinator and radial 
extensor muscles form a well defined prominence above and in front of the 

1 Maisonneuve: Gaz. des Hdpitaux, 1867, p. 145. 



COMPLETE DISLOCATIONS OUTWARD, 



309 



joint ; the tendon of the triceps shows as a prominence directed down- 
ward and outward, and the tendon of the biceps can sometimes be felt 
running in the same direction in front. 

The outlines of the lower end of the humerus can be distinctly traced 
from the epitrochlea outward to the capitellum ; the external epicondyle 
is masked by the ulna, but sometimes can be felt by pressing the finger 
deeply in above the latter. The cup-shaped surface of the head of the 
radius can be felt unless it has been carried so far inward by the prona- 
tion of the limb that it rests against the front of the humerus. 

In the third variety, " supra-epicondylar" the forearm is flexed at, or 
nearly at, a right angle and pronated. The limb is shortened from one 
and a half to two inches, and the transverse diameter of the lower part of 
the arm is increased. The greater the displacement upward, the greater is 
the passive mobility of the limb in the plane of flexion and extension. It 
is noted in some cases also that the lateral mobility was marked. The 
lower end of the humerus is accessible to the touch even more completely 
than in the two preceding varieties, for it projects completely below, and 
even its external condyle can be traced. The deformity on the outer side 
varies with the extent and character of the final displacement, for the 



Fig. 82. 



Fig. 83. 





Complete outward dislocation of the elbow. (Hamilton.) 

bones of the forearm are sometimes car- 
ried backward, crossing the humerus, or, 
as in Maisonneuve's and Cloquet's cases, 
carried forward to the front of the 
humerus. 

It is noteworthy that in three of the 
four cases in which reduction was not 
made the patients had good control of the 
limb and a free range of motion was estab- 
lished. Wylie's patient (Fig. 83) thought 
his arm was as serviceable as ever. 
Robert's patient was seventy years old and his injury dated from 
infancy ; he had an extensive range of flexion and extension. In 



Complete outward dislocation. (Denuc£.) 



310 DISLOCATIONS OF THE ELBOW. 

Denuce's case (Fig. 82) the olecranon projected nearly an inch behind 
the humerus, the arm could be fully extended and flexed nearly to a 
right angle. In Nekton's case there was flexion nearly at a right angle. 

It is also noteworthy that in no case were there symptoms of inter- 
ference with the' circulation, and in only one case (Mears) were there 
symptoms of injury to the nerves. In his there was pain in the fingers 
and numbness in the distribution of the median nerve. 

Treatment. — Reduction has been effected without difficulty in all the 
recent cases by extension and direct manipulation of the upper ends of 
the radius and ulna. The laceration of the ligaments and muscles is so 
great that the bones are freely movable, and special manoeuvres intended 
to relax opposing bands are seldom necessary. Exceptions to this may be 
found sometimes in the first and second varieties ; in the first the head 
of the radius may pass through and be caught, as apparently happened 
in Puech's case, between two muscular bundles which may then need to 
be relaxed by flexing and abducting the forearm; in the second, which 
appears sometimes, as has been said, to differ from the incomplete out- 
ward dislocations only in the addition of pronation of the forearm, the 
external lateral ligament remaining untorn, the first movement must be 
to supinate the limb and thus turn the sigmoid cavity under the capitellum 
and bring the head of the radius to the outer side ; the dislocation is 
then an incomplete outward one, and is reduced accordingly. 

The only reported case in w T hich the attempt to reduce has been fol- 
lowed by grave consequences is that of Michaux, 1 quoted in Chapter 
VIII. p. 80, and generally called a dislocation backward and outward. The 
reason for thinking that it may have been primarily a dislocation outward 
is that after amputation the tendons of the biceps and brachialis anticus 
were found behind the external condyle, and also that during the efforts 
to make reduction the ulna and radius always moved toward the outer 
side. The second attempt to reduce was followed by arrest of pulsation 
in the radial and ulnar arteries and gangrene of the limb. The brachial 
artery and median nerve had been ruptured and lay behind the external 
condyle. The patient was ten years old. 

Dislocations of the Forearm Forward. 

Although mentioned by Hippocrates and characterized by him as the 
most painful of all and fatal in a few days, and admitted by all subse- 
quent writers, the first recorded case (and that a questionable one) of this 
dislocation was published only a hundred years ago, and the number has 
now barely reached 20. 2 

i Keported by Debruyn, Annales de la Chir. Fran?, et Etrangere, 1843, vol. 9, 
p. 56. 

2 The bibliography is as follows: Evers, Monin, G-uyot, Wittlinger, quoted by 
Streubel in Prager Vierteljahrschrift, 1850, 2, p. 37, and by Malgaigne, loc. cit., p. 
626 ; Guerre, quoted by Pingaud in Diet. Encyclopedique, 1st. ser. vol. 21, p. 708 ; 
Chapel, quoted by Malgaigne, loc. cit., p. 617, as a dislocation outward; Colson, 
Leva, quoted by Debruyn in Annales de la Ohirurgie Franpaise et Etrangere, 1843, 
vol. 9, p. 44 and 45, and by Streubel ; Kichet, Archives generates, 1839, vol. 6, p. 
472; Prior, Lancet, 1844, ii. p. 366; Ancelon, L'Union Medicale, 1859, vol. 3, p. 
394; Canton, Dublin Medical Journal, 1860, ii. p. 24; Secrestan, Gazette des 



DISLOCATIONS OF THE FOREARM FORWARD. 311 

Of the 11 cases in which the age is mentioned, 1 was 6 years old, 2 
were 8, 1 was 14, 2 were 15, and 1 each 18, 20, 34, 38, and 40 years 
old; another was an "adult." The cause in the greater number of 
cases appears to have been a fall upon the flexed elbow ; in one (Prior) 
it was a blow by the handle of a crane upon the back of the elbow ; in 
one certainly (Date), and probably in others, it was a fall upon the palm 
of the hand ; in one (Caussin) the patient's hand was caught between 
two cogwheels and both bones of the forearm were broken at the middle 
as well as dislocated ; and in one (Morel-Lavallee) the patient fell from 
a wagon and was run over, the wheel passing across the elbow and 
breaking the olecranon and coronoid process. 

In 6 of the cases the olecranon was broken, and in these the mechanism 
of the dislocation is easily understood, for, the resistance of the olecranon 
being removed, the two bones can be easily displaced forward and upward 
along the front of the humerus by a force acting upon the back of the 
forearm. In the case of a fall or of a blow upon the flexed elbow the 
direction of the force is probably inclined somewhat away from the axis 
of the forearm and is more nearly parallel with the posterior portion of 
the articular surface of the olecranon, and it must be great enough to 
rupture the lateral ligaments without the aid of leverage, unless the 
flexion of the elbow is at the same time carried so far that the tip of the 
coronoid process and the anterior edge of the head of the radius are 
brought into contact with the anterior surface of the humerus above the 
joint, and a fulcrum thus created by the aid of which the ligaments may 
be ruptured. All attempts to reproduce the dislocation upon the cadaver 
by this mechanism, forced flexion and direct impulsion, have failed, 
except after preliminary division of the lateral ligaments. The small 
size of the projecting part of the olecranon and its cartilaginous character 
in children favor displacement by this mechanism. 

In the case of a fall upon the hand there is clinical evidence to show 
that this form is closely allied to the lateral dislocations, and that it is 
produced by lateral outward flexion supplemented by sufficient torsion 
(supination) of the limb to bring the olecranon forward under the troch- 
lea ; in several of the cases the displacement was outward as well as 
forward ; in Chapel's so far outward that the case has been classed with 
the lateral dislocations. 

It has also been claimed that the dislocation may be produced by 
exaggerated hyperextension, bringing the upper surface of the olecranon 
down along the back and under surface of the trochlea, but Guerin's 
experiments failed to confirm this, even when the dorsal flexion was 

Hopitaux, 1860, p. 598 ; Caussin, L'Union Medicale, 1861, vol. 11, p. 475, and 
Bulletins de la Societe de Chir irgie, 1861, vol. 2, p. 451 ; Richet, Bull, de la. Soc. 
de Chirurgie, 1859, vol. 9, p. 110 ; Morel-Lavallee, Idem, p. 107 ; Greenaway, 
quoted by Hutchinson, Med. Times and Gazette, 1866, i. p. 409 ; Langmore, 
Lancet, Abstract in New York Medical Record, 1867, vol. 2, p. 10 ; Rigaud, Bulletins 
de la Societe Anatomique, 1870, p. 15; Date, Lancet, 1872, ii. p. 597; Mons, 
Deutsche Mil. Zeitschrift, 1877, p. 401 ; quoted by Poinsot, loc. cit., p. 951 ; Kron- 
lein, Deutsche Chirurgie, Lief. 26, p. 30 References have also been made to a case 
by Ferguson, Surgery, 3d. ed. p. 241, one by Roser, Chirur. Anat., 1844, p. 477, 
and one by Flaubert. 



312 DISLOCATIONS OF THE ELBOW. 

carried so far that the whole length of the forearm rested against the 
back of the arm ; he found the posterior portion of the lateral ligament 
remained untorn and effectually opposed the displacement forward. 

Pathology. — One autopsy (Richet), three amputations (Canton, Morel- 
Lavallee, Rigaud), two compound fractures of the olecranon without 
amputation (Richet, Guerre), one compound dislocation without fracture 
(Prior), and experiments upon the cadaver show how great the laceration 
sometimes is. In Prior's case, in which the patient was struck upon 
the "under side of the left arm at the elbow-joint" by the rapidly 
revolving handle of a crane, there was a large wound at the point where 
the blow was received, " occasioning a general disconnexion of its parts, 
muscular and otherwise, excepting immediately in front." The radius 
and ulna were driven upward and forward on the humerus ; the condyles 
of the latter and its shaft for two and a half or three inches projected 
through the wound nearly at right angles with the forearm, as completely 
stripped as if cleaned with a knife. There was no fracture. Reduction 
was made ; the patient recovered after much suppuration in and around 
the joint, and the final result was good, " the limb gaining in freedom 
and power." 

In Canton's case, the patient, a man forty years old, was thrown from 
a wagon ; apparently he struck upon the extended hand, but the forearm 
was immediately flexed and twisted under his chest. The forearm was 
flexed, the hand supinated, the swelling very great, and the skin tense 
and threatening to slough over the internal condyle. The antero-posterior 

and lateral diameters of the joint were in- 
Fig. 84. creased, and the head of the radius could be 

indistinctly felt externally and anteriorly. 
The diagnosis was not made, and " attempts 
to correct the maladjustment" failed; after 
a delay of forty-eight hours, during which 
the swelling increased and sloughing was 
established, amputation well above the con- 
dyles was resorted to. 

Examination of the limb showed (Fig. 84) 
that the upper surface of the olecranon rested 
against the front of the capitellum ; the 
annular and interosseous ligaments were 
Forward dislocation of the elbow; whole, the anterior ligament was ruptured 
canton's case. except in its centre, the posterior and both 

lateral ligaments ruptured. The triceps was 
completely detached from the olecranon. The two radial extensor mus- 
cles and all the muscles arising from the epicondyle except the supinator 
brevis and the anconeus were detached, as was also the epitrochlear head 
of the flexor carpi ulnaris. The ulnar nerve was torn behind the condyle. 
The other large nerves and the main vessels were uninjured. 

Morel-Lavallee's patient was a man thirty-eight years old who had 
fallen from and been run over by a wagon, the wheel passing across the 
front of the elbow from the outer to the inner side. There was a com- 
pound fracture of the olecranon, and the skin was broken on each side 




DISLOCATIONS OF THE FOREARM FORWARD. 313 

of the joint. There was great swelling ; passive movements were very 
free. The olecranon remained in place : the radius and ulna were dis- 
placed forward and outward. Amputation was done on the fourteenth 
day. The coronoid process was found to have been broken off parallel 
to the anterior surface of the ulna and turned outward ; it remained 
attached to the ulna by the soft parts. The truncated end of the ulna 
rested against the capitellum. 

Richet's first patient was eighteen years old and had fallen from a 
height of forty-five feet. The forearm was slightly flexed and in supin- 
ation, and was immovable ; it was shortened an inch, measuring from 
the epicondyles to the lower ends of the radius and ulna. The olecranon 
was in place and movable ; two inches below it was a large wound through 
which the lower end of this fragment projected. The head of the radius 
and the broken end of the ulna were recognizable in the fold of the 
elbow a fingerbreadth above the condyles. Reduction Avas easy by trac- 
tion, but recurrence at once followed. The patient died three hours 
later. The autopsy showed the annular ligament to be intact. 

In addition to these two varieties, dislocation with and without fracture 
of the olecranon, the difference between which is so important, there is 
another, based upon clinical and experimental evidence to which the 
name incomjolete is given ; in it the upper end of the olecranon rests 
against the under and anterior surface of the humerus instead of passing 
upward in front of it. So far as can be inferred from the reported cases 
it is the most common form. The use of the terms first and second 
degree, to distinguish between the two forms, is, I think, to be preferred 
to that of incomplete and complete. 

In Chapel's case the additional outward dislocation, which is noted in 
several of the others, was so great that Malgaigne classes it with the 
outward dislocations. The patient was a boy fourteen years old. The 
radius formed a marked prominence under the skin on the outer side ; on 
its inner side could be felt the olecranon and its sigmoid cavity, with the 
coronoid process in front. The two bones overrode the humerus in front 
about two centimetres ; the epicondyle lay behind the ulna. Mons's case 
seems to me to be of the same kind. It is quoted by Poinsot as a 
unique example of divergent dislocation, ulna forward and radius out- 
ward. The description is limited to this statement and does not defi- 
nitely exclude the possibility that the ulna may have been displaced 
outward as well as forward. This supposition seems justified by the fact 
that the injury was caused by direct violence upon the completely flexed 
elbow. 

Fracture of the epitrochlea has been observed in one case, Date's, a 
boy fourteen years old, and this is the one in which the evidence that the 
dislocation was produced by external lateral flexion in a fall upon the 
hand is most complete. The head of the radius was prominent outside 
of and below the outer condyle ; above it was a deep depression in which 
the condyle could be obscurely felt ; the olecranon was below its usual 
position, resting with its extreme end against the trochlea (first degree, 
or incomplete.) The limb was semi-flexed. Reduction was easy under 
chloroform ; the radius first, and then the ulna, going back into place 



314 DISLOCATIONS OF THE ELBOW. 

with a distinct snap. If this account of the positions of the two bones 
is accurate the annular ligament was probably torn. 

Symptoms. — In five of the cases uncomplicated by fracture it is stated 
that the forearm was lengthened, more than an inch in one of them, and 
with this coincided a position of the limb which is mentioned in several 
others, namely slight or partial flexion, which could generally be changed 
somewhat in either direction. In one in which the range of motion is 
specified, Longmore, the limb was held at an angle of 130°, could be 
flexed to a right angle, and extended to 160° ; in another, Colson, 
hyperextension could be made without causing pain, and during the 
movement the olecranon passed forward between the biceps and pronator 
teres. 

In correspondence with this lengthening there is flattening of eacji 
side and of the back of the elbow, unless the swelling is sufficient to 
mask it, with prominence of the inner and sometimes of the outer con- 
dyle, and the formation of a transverse sulcus appreciable by the touch 
behind between the humerus and the olecranon. In one case the forearm 
was also abducted. In Canton's case the forearm was flexed beyond a 
right angle ; the olecranon rested against the capitellum, and the triceps 
was torn completely from it. It seems probable that detachment or rup- 
ture of the triceps is a necessary condition of the passage of the olecranon 
to any distance along the front of the humerus, and that the existence 
or absence of the detachment may constitute the essential difference 
between the complete and incomplete forms, or the first and second 
degrees. The clinical features which differentiate the two forms are that 
in the lesser form the olecranon is prominent below the humerus when 
the elbow is flexed, and the forearm is lengthened when it is extended or 
but slightly flexed. In the second, " complete" form, the forearm is 
more or less shortened when extended, but is lengthened when flexed at 
or near a right angle, and its antero-posterior diameter is increased 
because of the projection of the coronoid process in the fold of the elbow. 
The biceps tendon can be recognized on the outer side of the latter, and 
beyond it the head of the radius. Posteriorly, in both forms, the 
olecranon fossa is empty ; the direction of the ulna also plainly indicates 
the change in the position of its upper end unless the swelling is great. 

Course and Prognosis. — In only one case, Canton, did the dislocation 
remain unreduced, and, as in this the diagnosis was not made because of 
the swelling, there is no reason to suppose that a suitable attempt to 
reduce would have been less successful than it proved in the others. It 
was also the only case, of those uncomplicated by a compound fracture of 
the olecranon, that did badly and in which amputation was thought to be 
necessary. The history of the case, moreover, suggests that the decision 
was reached rather hastily and on grounds that might be deemed insuffi- 
cient. With this exception, there is nothing to show that an uncompli- 
cated dislocation of this kind is more likely to be followed by grave 
consequences than one of another form in which the displacement is 
marked and the laceration notable. 

Of the 7 compound dislocations, of which 6 were complicated by 
fracture of the olecranon, 3 recovered, 2 underwent amputation after the 
joint had suppurated, 1 died three hours after the accident, which was a 



DIVERGENT DISLOCATIONS OF RADIUS AND ULNA. 315 

fall from a height of forty-eight feet, and in 1, Kronlein, the result is 
unknown. Of the 3 recoveries, the joint suppurated in 2, Prior, 
Richet's 2d, the process ending in ankylosis in one of them ; in the 
remaining 1 the patient recovered apparently without suppuration, the 
fracture of the olecranon united by a fibrous band one centimetre long, 
and two and a half months after the accident the hand could be brought 
to the mouth and the elbow extended to an angle of 150°. Whether 
antiseptic methods will improve this poor record remains to be seen. 

Treatment. — In all the cases in which the olecranon rests against the 
lower part of the end of the humerus, the so-called imcomplete disloca- 
cations, reduction has been easily effected by pressing or pulling the 
upper end of the forearm downward and backward, or by flexing the 
limb against the knee or the arm of an assistant placed in the fold of 
the elbow. In Greenaway's case the bones slipped into place almost 
spontaneously when the elbow was flexed. 

In the cases in which the bones are displaced further upward it is 
desirable to flex the limb within a right angle and then to pull the upper 
ends of the bones back into place by a strap passed around the front of 
the forearm close to the elbow. 

Dislocations complicated by compound fracture of the olecranon must 
be treated in accordance with the general principles of treatment of com- 
pound articular fractures, of which they are a severe form, severe because 
of the greater extent of the laceration of the soft parts. 

Divergent Dislocations of the Radius and Ulna. 

The characteristic feature of this form is that the radius and ulna do 
not accompany each other, but are displaced in divergent directions. Two 
varieties have been observed : the antero-posterior, in which the ulna 
passes up behind the humerus, and the radius passes up in front, and of 
which there are 11 recorded cases j 1 and the transverse, of which there is 
only a single case, in which the divergence was mainly lateral, the 
olecranon passing to the inner side behind the epitrochlea, and the 
radius to the outer side. 2 Several authors make an additional variety, 
ulna backward, radius outward, on the basis of the case of Samuel 
White quoted by Cooper (Disloc. and Fraets. Am. Ed. page 384) 
which seems to me to be a dislocation of both bones backward and out- 
ward ; and Poinsot makes a fourth variety of the case of Mons which I 
have placed among dislocations of both bones forward. 

1 Bulley, Provincial Med. and Surg. Journal, 1841, quoted in the Gazette Medi- 
cale, 1841, p. 666 ; Michaux, quoted by Debruyn in Annales de Chir. Fran^aise 
et Etrangere, 1843, vol. 9, p. 52; Mayer, Gazette des Hopitaux, 1848, p. 232; Von 
Pitha, Pitha and Billroth's Chirurgie, 4th vol. 2d Abt. B. p. 78; Chevalier, Arch. 
Med. Beiges, Oct. 1870, quoted by Bardeleben, Chirurgie, vol. 2, p. 759 ; Gripat, 
Bull, de la Societe Anatomique/ 1872, p. 176; Arnozan, Bordeaux Med. 1873, p. 
402, quoted by Poinsot, loc. cit., p. 945; Tillaux, Gazette des Hopitaux, 1877; p. 
786; Minich, Lo Sperimentale, 1880, quoted by Poinsot; Mason, 1ST. Y. Medical 
Record, 1880, vol. 17, p. 397 ; Scott, Bristol Med. Chir. Journal, March, 1886, p. 36. 

2 Guersant, reported by Warmont in Revue Medico-Chirurgicale. vol. 16, p. 303, 
quoted by Pingaud in Diet. Encyclopedique, art. Coude, p. 600, and. by Poinsot. 



316 DISLOCATIONS OF THE ELBOW. 

A. A?itero-posterior. — Excluding Chevalier's case, of which I have 
no details, the ten patients were, with one exception, Tillaux, males, 
and with two exceptions, adults; one was nine years old, Arnozan; 
another thirteen, Gripat. The cause was usually a fall from a con- 
siderable height, or with violence, as from a moving railway car, a horse, 
or a wagon ; in one it was a fall while carrying a heavy timber, in 
another while wrestling ; and in Tillaux's the patient, while lighting a 
match, struck her elbow against a piece of furniture behind her; the 
pain was so great that she fainted and fell to the floor, where she was 
found with her elbow abducted and flexed. Scott's patient was thrown 
from a horse, striking upon his head and hands; he found his elbow 
dislocated and the forearm partly flexed ; a bystander pulled it straight, 
and he felt something give way in the joint, and a bone appeared to 
slip forward ; possibly a dislocation of the ulna alone backward was 
thereby transformed into the divergent one which was afterward recog- 
nized. Von Pitha's patient fell head foremost from the second story of 
a building upon a pile of planks between which the extended forearm was 
caught and held while the body was violently precipitated backward. 

Pingaud (loc. cit., p. 598), experimenting upon the cadaver, found it 
easy to produce the dislocation by forced pronation of the forearm 
after division of the internal lateral ligament ; this fact, taken in con- 
nection with the fall upon the hand noted in several of the cases, indi- 
cates that the mechanism, in these cases at least, is a lateral outward 
flexion, by which the internal lateral ligament is ruptured, followed or 
accompanied by forcible pronation, and then by the direct movement 
downward of the humerus between the two bones. Fracture of the 
epitrochlea observed in one case, Arnozan, supports the theory of outward 
lateral flexion. In two cases, von Pitha, Gripat, the coronoid process 
was broken ; in both the fall was from a considerable height. 

The explanation of the mechanism in the two cases in which the 
injury was attributed to a fall upon the abducted and flexed elbow, 
Michaux and Tillaux, shares in the difficulty which attaches to the 
explanation of dislocation of both bones backward by the same cause. 
If the alleged rotation of the ulna backward and outward around the 
radius, by which the internal lateral ligament is torn, is accepted, it will 
not be difficult to conceive that the radius may remain in front; but even 
this leaves unexplained the forcible descent of the humerus between the 
two bones which requires the rupture of the annular and interosseous 
ligaments. 

Pathology. — Two of the patients, von Pitha, Gripat, died of the 
associated injuries, but the displacement at the elbow was much greater 
than that observed in the other cases. 

In von Pitha's the limb was shortened about three inches, and very 
much enlarged at the elbow. The olecranon and radius were easily recog- 
nized behind and in front of the humerus respectively, and were reduced 
by slight traction, but the reduction had no permanence. The skin was 
unbroken. The autopsy showed a wide separation of the radius and 
ulna from each other, complete rupture of the capsule, and of the 
annular, interosseous, and both lateral ligaments, fracture of the coronoid 
process, and avulsion of the biceps and brachialis anticus. 






DIVEKGEXT DISLOCATIONS OF RADIUS AND ULNA. 317 

In Gripat's case, a boy thirteen years old. the coronoid process had 
been broken off and the olecranon had passed almost directly upward, 
remaining close to the posterior surface of the humerus : the radius was 
displaced forward and outward. The internal lateral ligament had been 
torn away at both its insertions : the external one remained attached at 
its upper insertion, and to the broken coronoid process, and part of the 
anterior ligament. . The annular ligament was torn away at its posterior 
attachment to the ulna. 

Symptoms. — The attitude of the limb is noted in seven cases ; in five 
it was slightly flexed, in two nearly straight ; in one case supinated, in 
the others midway between pronation and supination, or slightly pro- 
nated. The general appearance of the region probably resembles that of 
dislocation of both bones backward, for in three of the cases the anterior 
position of the radius was not noticed until after the ulna had been 
reduced. Excluding the two fatal cases, the displacement of the ulna 
upward is still very marked; four centimetres in Tillaux's case, two or 
three finger-breadths in Michaux's, and one and a half inches above the 
condyles in Scott's; in Tillaux's it was also displaced somewhat to the 
inner side. In three cases the position of the radius is exactly noted; 
in two. Bulley. Tillaux. it was in the coronoid fosssa : in one. Mason, it 
rested on the outer portion of the humerus. 

Active movements, both flexion and rotation, are impossible, and 
passive movements restricted and painful. 

In two cases, Mayer. Tillaux. reduction failed, the attempt being 
made on the fourteenth and eighth days respectively. In both the 
joint remained quite stiff. In Mason's the attempt was made on the 
nineteenth day ; prolonged efforts under ether brought the ulna into 
place, but the radius slipped toward the outer side and could not be 
entirely reduced. The final result is not known. In the others reduc- 
tion was effected without much difficulty, usually ihe ulna first, then the 
radius, but in Bulley 's the radius remained a little forward, and was 
finally reduced by continuous pressure upon it. 

Treatment. — Traction should be made in the direction of the axis of 
the forearm to bring the ulna into place, and in case of need it might be 
well to combine it with some outward lateral flexion to avoid the opposi- 
tion of the external lateral ligament ; after the ulna is reduced the radius 
should be pressed back into place with the thumbs aided by pronation 
and adduction of the forearm. It is quite likely that the return of the 
radius to its place may be impeded by the interposition of the annular 
ligament. 

B. Transverse — Of this variety there is. as above stated, only one 
recorded case, Guersant's. It is as follows: The patient was a boy 
fifteen years old, who fell from a tree, three or four metres, on his left 
side, striking on the palm of his hand. The elbow was enormously 
swollen; its transverse diameter was greatly increased, and the antero- 
posterior one seemed lessened. The head of the radius formed a con- 
siderable prominence entirely to the outer side of the epiphysis of the 
humerus and a little upward along its outer border. It was so far dis- 
placed outward that there seemed to be an interval betweeen it and the 
epicondyle; the skin was very tightly stretched over it. 



318 DISLOCATIONS OF THE ELBOW. 

The olecranon was displaced inward behind the epitrochlea, which it 
embraced in its sigmoid cavity. In the great space between the olecranon 
and radius lay almost the entire articular surface of the humerus. 

The forearm was semi-flexed, and in a position midway between pro- 
nation and supination ; voluntary movements were impossible, passive 
movements very restricted. There was also a fracture of the forearm 
three centimetres from the wrist. 



CHAPTER XX. 

dislocations at the elbow. — {Continued.) 
isolated dislocations of the ulna and radius. 

Dislocations of the Ulna alone. 

Sedillot, in a paper presented to the Academie des Sciences in 1837, 
was the first of modern writers to call attention to this class of disloca- 
tions, although Sir Astley Cooper had previously described as of this 
kind a specimen preserved at St. Thomas's Hospital. Malgaigne and 
other surgeons and writers have strenuously opposed the interpretation of 
cases cited in support of the claim that the occurrence of this form is 
possible, and have denied the possibility on anatomical grounds, claiming 
that the ulna cannot be displaced backward and upward unaccompanied 
by the radius, except after rupture of the interosseous ligament and those 
uniting the lower ends of the bones, of which there is no clinical evidence. 
The specimen figured and described by Cooper is claimed by them to 
be one of dislocation backAvard of both bones, and one presented by 
Robert to the Societe de Chirurgie, in 1847, was declared by Malgaigne 
to be of the same character. Malgaigne admits, however, on the 
authority of a case observed by himself, the possible dislocation of the 
ulna alone backward and to the outer side behind the radius. The 
dispute is in part one of terms ; it must be admitted, I think, that the 
head of the radius in some of the reported cases has changed its rela- 
tions with the capitellum, but the change is a very slight one, a simple 
slipping backward or forward for a distance of a few millimetres, without 
a change in its level corresponding to that of the ulna. The erroneous 
belief in the impossibility of the occurrence without the extensive lacera- 
tions mentioned arose apparently from a failure to consider the effect of 
a change in the relation of the axes of the arm and forearm, for while the 
occurrence of an isolated dislocation of the ulna backward and upward 
might be impossible while those relations remained unchanged, yet if, 
the joint being extended, the forearm is adducted, turning upon the head 
of the radius as a centre, the olecranon must necessarily move upward 
behind the humerus ; or, the joint being flexed at a right angle, the same 
movement of adduction or the equivalent outward rotation of the humerus 
will displace the olecranon backward. 

The following recorded cases serve as the basis of the description to be 
given. Some in which the correctness of the diagnosis is in doubt, or of 
which I have not been able to consult the detailed reports, have been 
omitted. 

Cooper, Dislocations and Fractures, Amer. Ed., 1844, p. 390 ; Bou- 
dant, Revue Medicale, 1830, vol. 1, p. 75, quoted in full by Sedillot ; 



320 



DISLOCATIONS AT THE ELBOW. 



Fig. 85. 



Sedillot, Gazette Medicate, 1839, vol. 7, p. 369; Diclay, Idem, p. 393; 
Brun (three cases), Idem, 1844, p. 580; Robert, G-azette des Hopitaux, 
1847, p. 272 ; von Pitha, Pitha and Billroth's Qhirurgie, vol. 4, Part 2, 
B, p. 87; Malgaigne, Luxations, p. 631 ; Duguet, Bulletins de la 
Societe Anatomique, 1863, p. 278 ; Mathieu, Gazette des Hopitaux, 
1866, p. 330 ; Waterman, Boston Medical and Surgical Journal, 1869, 
vol. 81, p. 187 ; Wilson, Canada Journal of the Med. Sciences, 1880, 
vol. 5 , p. 346 ; Waters, Maryland Medical Journal, 1883, vol. 10, 
p. 402. 

The dislocation presents itself under three forms. In the first, that in 
which the displacement is slightest, the ulna is carried backward, either 
directly or by inward rotation of the forearm about the radius as a centre, 
until the coronoid process has cleared the trochlea, and 
then is moved slightly upward behind it by adduction of 
the forearm (Fig. 85) ; in the second form, the movement 
upward is prolonged until the coronoid process lodges in 
the olecranon fossa; in the third, the primary movement 
of rotation is prolonged until the olecranon lies behind the 
radius. The first form is the most common, and is some- 
times termed " incomplete," in accordance with a similar 
use of the term in the backward dislocation of both bones ; 
of the second form there are only two recorded examples 
(Malgaigne, Wilson). Some writers make an additional 
variety, dislocation backward and inward, a distinction 
which it does not seem necessary to preserve. 

The cause in the larger number of cases has clearly 
been a fall upon the outstretched hand ; in one, Brun, a 
blow received upon the elbow from behind while the weight 
of the body rested upon the extended arm. In other cases 
the cause was thought to have been a fall upon the elbow, 
but it does not appear in the accounts that the opinion 
had any better basis than the supposition that, as the 
elbow was the part injured, the violence must have been 
directly received upon it. 

In von Pitha's case the injury was received in such a 
way that the mode of production is clearer than in most 
accidents, and, as the the case is typical in other respects, I reproduce 
the account. 

A girl six years old and her little brother were engaged in a trial of 
strength, in which each sought to move an open door against the other's 
opposition, the girl standing with her back against the wall and her out- 
stretched hands against the door, the hinges being at her left side. Two 
other brothers came to the help of the first, and under their combined 
efforts the girl's left arm suddenly doubled up with an audible snap, and 
when von Pitha examined it half an hour later, he found " the most 
distinct picture of a dislocation of the ulna backward." The thin arm 
was in almost complete extension, the forearm being slightly inclined 
toward the ulnar side ; the fold of the elbow was somewhat raised by the 
projecting trochlea ; the olecranon was very prominent behind, but barely 
raised above its normal level ; the elbow was notably thicker, but not 




Dislocation of 
ulna alone back- 
ward, first form. 
(Sedillot.) 



DISLOCATIONS OF THE ULNA ALONE. 321 

broader ; the head of the radius was in its place ; pronation and supina- 
tion were but slightly restricted, but the least movement of flexion was 
very painful. Reduction was easily accomplished by grasping with the 
left hand the humerus above the condyles, and with the right the forearm 
in such a way that the thumb and fingers especially compressed the ulna, 
and then supinating, abducting, and extending until there was slight 
dorsal flexion ; at this moment he distinctly felt the lifting of the 
coronoid process, and on increasing the traction it suddenly slipped back 
over the trochlea with a snap. Pain at once ceased, and the patient 
could flex the joint. 

Experiments upon the cadaver by Sedillot and Streubel 1 indicate that 
the mode of production is similar to that of backward dislocations of both 
bones together — that is, the forearm is abducted (Streubel) or hyper- 
extended (Sedillot) until the internal lateral ligament yields, and then 
rotated inward and adducted to carry the coronoid process past the trochlea 
and engage its point against the posterior surface of the latter. If the 
adduction is increased, and especially if at the same time the orbicular 
ligament is torn, the olecranon rises to a higher point and may pass to 
the inner side. If, on the other hand, adduction is absent and the rota- 
tion is prolonged, the olecranon is carried around behind the radius, and 
the third form is produced. 

Pathology. — Three specimens (Cooper, Robert, Duguet) and one 
compound dislocation (Boudant) furnish but scanty information of the 
pathological details, for which we must mainly depend upon experiment. 
Of the three specimens, Robert's alone was of a recent case. Cooper's 
specimen, preserved in St. Thomas's Hospital, is thus described by him : 
"It had existed a great length of time without reduction ; the coronoid 
process of the ulna was thrown into the posterior fossa of the humerus ; 
the olecranon is seen projecting behind the os humeri ; the radius rests 
upon the external condyle, and has formed a small socket for its head, in 
which it was able to roll. The coronary and oblique ligaments had been 
torn through, and also a small part of the interosseous ligament. The 
lower extremity of the internal condyle of the humerus seems to have 
had an oblique fracture in it ; but I doubt whether it had been broken, 
or only altered in form, on account of the unnatural position of the ulna ; 
if it had been broken it was reunited. The triceps was thrown backward, 
and the brachialis internus muscle was stretched under the extremity of 
the humerus/' 

The accompanying figures (Figs. 86 and 87) indicate that the appear- 
ance of fracture of the internal condyle was due to new formation of bone 
on its posterior aspect, and that the front portion of the capitellum had 
disappeared by absorption. 

Duguet's specimen was taken from a man, fifty years old, who had 
received the injury twenty years previously. There was ankylosis in the 
extended position, but pronation and supination were preserved. The 
ulna was displaced backward and upward so that its upper end was two 
centimetres above the line uniting the two epicondyles, and a nearthrosis 
had formed between the tip of the olecranon and the back of the humerus 

1 Streubel: Prager Vierteljahrschrift, 1850, ii. p. 54. 
21 



322 DISLOCATIONS AT THE ELBOW. 

above and a little to the inner side of the olecranon fossa. It is probable, 
therefore, that the coronoid process was lodged in the olecranon fossa. 
Concerning the radius two statements are made : the first is that it had 
preserved its relations with the external condyle ; the second, that it was 
appreciably (sen'siblement) displaced forward, and preserved its move- 
ments of rotation. I understand these to mean that the head was directly 
below the condyle and a very little in front of the position it would 
normally occupy in that attitude (extension) of the limb. 

Fig. 86. Fig. 87. 





Dislocation of the ulna alone backward ; inner side. The same outer side. 

(Cooper.; (Cooper.) 

In Robert's case the injury was caused by a fall on the palm of the 
hand ; the limb was partly flexed, the olecranon prominent posteriorly 
and elevated; the head of the radius could not be felt because of the 
swelling, but it could be moved backward and forward with cartilaginous 
crepitation. At the autopsy the coronoid process was found in the ole- 
cranon fossa, and the radius in place ; the humerus appeared to have 
been twisted so that its anterior aspect looked outward (in other words, 
the forearm was adducted) ; the annular ligament and some of the fibres 
of the external lateral ligament were torn. The condition of the internal 
lateral ligament is not mentioned. The brachialis anticus and brachial 
artery were ruptured. 

Boudant's patient was a man, forty-nine years old, who had fallen 
from the first story of a building and received a compound dislocation ; 
the wound was eighteen or twenty lines in length on the inner and 
anterior part of the elbow, and was thought to have been caused by contact 
with a large, rough stone. It seems, however, not unlikely that it was 
caused from within outward by the pressure of the trochlea in hyper- 
extension of the joint. The olecranon, which was prominent posteriorly, 
could be seen through the wound, and the finger introduced into the 
latter recognized the radius in place. Reduction was easy, and the 
patient made a good recovery. 

The experiments made upon the cadaver show that the internal lateral 
ligament is always ruptured, and that the orbicular ligament escapes 
injury if the displacement is not great. 

Symptoms. — In the first and second forms, dislocation backward and 
upward, the limb is usually in almost complete extension (in Cooper's,. 



DISLOCATIONS OF THE RADIUS ALONE. 323 

Duguet's, and Waterman's cases it was flexed at a right angle), and 
cannot be flexed without causing much pain, but pronation and supination 
are free and painless. The normal deflection of the forearm toward the 
outer side is lost, and in its place may be a deflection toward the ulnar 
side. This deflection is easily recognized by the eye when the limb is 
extended, but when the joint is flexed at or near a right angle it may be 
overlooked unless comparative measurements are made ; in Diday's case 
the length of the ulnar border, from the epitrochlea to the lower end of 
the ulna, was an inch shorter than that of the other arm, while the radial 
borders were of equal length. The antero-posterior diameter of the joint 
is increased, and the fold of the elbow is filled out by the trochlea. 

The olecranon is prominent behind the humerus, and may rise well 
above the line of the epicondyles ; it may be nearer the epitrochlea than 
usual. The head of the radius, unless the swelling is too great, can be 
felt in its place, and it is by the determination of this fact, together with 
the displacement of the olecranon, that the diagnosis of the variety of the 
dislocation is made. 

In the two recorded cases of the third form, dislocation of the ulna 
backward and outward behind the radius (Malgaigne, Wilson), the elbow 
was flexed nearly at a right angle. In Malgaigne's the forearm was pro- 
nated and deviated outward ; the greater sigmoid cavity was directed 
outward, the coronoid process outward and forward. This attitude of 
the ulna suggests that the dislocation was not effected by rotation of the 
forearm. 

Treatment. — In two cases (Cooper, Duguet) reduction was not made ; 
in the others it was easily obtained. Waterman tried Cooper's method 
of the knee in the elbow, and Skey's of traction upon the upper part of 
the flexed forearm in the line of the humerus without success, and then 
easily reduced by hyperextension. The readiest method in the first and 
second forms appears to be that employed by von Pitha, and described 
above, supination, abduction, and hyperextension of the forearm. Mal- 
gaigne and Wilson reduced (third form) by direct pressure upon the 
olecranon, first backward to free it from the radius, and then inward. 

(A case described by Richet 1 as a new kind of dislocation by rotation, 
seems from its title, and from some of its features, to belong to this class, 
but the account is so incomplete that is not available.) 

Dislocations of the Radius Alone. 

Although statistics show that these dislocations are not very rare, 
three and three-quarters per cent, according to Kronlein (see Chapter L, 
Table I.), and, although the earliest writers mentioned them, yet they 
were almost completely lost sight of until about one hundred and fifty 
years ago, and even now are far from being clearly understood. Petit, 
while admitting their possibility, claimed that they were exceedingly 
rare, and although Duverney, in 1751, gave a detailed account of two 
forms, they were still looked upon as so rare that when, in the latter 

1 Richet : Nonveau genre de luxation incomplete du coude par pivotement. Gaz. 
des Hopitaux, 1879, p.737. 



324 DISLOCATIONS AT THE ELBOW. 

part of the century, Butet reported a case to the Academie de Chirurgie, 
Sabatier and Louis were sent to Etampes, a journey of sixty miles, to 
verify it. Since that time observations have accumulated, and four varie- 
ties are now well established, the dislocations forward, backward, and 
outward, and one seen exclusively in children, and caused by traction 
upon the wrist, the nature of which is not entirely undisputed, but is 
generally thought to be a diastasis or direct separation ; it is usually 
termed dislocation by elongation. 

The mode of production of all the forms is still obscure, and the 
numerous experiments that have been made upon the cadaver by various 
investigators, Roser, Malgaigne, Streubel, Denuce, Pingaud, Barros, 
while they have shown how the dislocations may be produced upon the 
cadaver, have not made it clear how they actually are produced in the 
patients who come under observation ; in some cases the clinical facts 
directly contradict the conclusions drawn from experiment. 

1. Dislocation backward. — This was one of the forms described by 
Duverney, and one of the earliest to be accepted as proved by later sur- 
geons. Its apparent frequency is in part due to the inclusion in the list 
of reported cases of those in which the dislocation is associated with frac- 
ture of the internal condyle (Fractures, p. 399), and probably also of 
others which belong in the somewhat vague group of dislocations by 
elongation. Two forms are described, the complete and the incomplete, 
the latter resting upon a few questionable, and one well observed case, 
that of Denuce : l a lad nineteen years old, fell from a swing, his pronated 
arm being caught under his body in such a way that the blow, as shown 
by an ecchymosis, was received upon the middle of the anterior aspect of 
the forearm. Pain ; limitation of motion ; the elbow semiflexed, the fore- 
arm fixed in complete pronation. A bone-setter tried in vain to reduce 
it, and a fortnight later the patient consulted Denuce, who found " behind 
the elbow, on a level with the condyle, and to the inner side of the epi- 
condyle, a small prominent tumor, which rolled under the finger in 
pronation, and was evidently the head of the radius, a little overlapping 
.its ordinary position posteriorly." 

Of the complete cases the instances are much more numerous, but in 
some of them the question arises whether the upper surface of the radius 
had entirely left the articular surface of the capitellum, or was not still in 
contact with it by its anterior portion ; if such contact did exist, the term 
"complete" can be properly applied only to the separation of the radius 
from the lesser sigmoid cavity of the ulna. 

The cause, in the majority of cases, appears to have been a fall upon 
the outstretched hand ; that the cause was a fall in most cases is certain, 
but whether it was upon the hand or the elbow is often far from clear, or 
whether it acted by direct impulsion or by exaggerated rotation. 

In some cases of backward dislocation of both bones it has been possible 
to restore only the ulna to its place, and the radius has remained perma- 
nently dislocated ; and in a case reported by Mason, 2 after reduction of 
a, backward dislocation of both bones in a man thirty-seven years old, 

1 Denuce: Diet, de med. and chir. pratiques, art. Coude, p. 777. 

2 Mason: New York Medical Kecord, 1880, vol. 17, p. 398. 



DISLOCATIONS OF THE RADIUS ALONE. 325 

recurrence of the dislocation of the radius was detected on the following 
day, and was attributed to his struggles while recovering from the effects 
of the ether. Some cases observed in adults, and thought to have occurred 
in childhood during convulsions have been attributed to muscular action, 
but the history usually leaves in doubt not only the mode of production, 
but even the character of the change, whether traumatic or congenital. 

In a case reported by Cameron 1 the character and mode of action of 
the violence are more clearly shown than usual, but they are entirely 
exceptional, and the case does not aid to clear up the obscurity in which 
the question is enveloped. The patient was a man fifty-two years old, 
who was caught between a wall and a cart backing against it in such a 
way that his forearm was compressed lengthwise between them, the palm 
of the hand being pressed against the cart, and the back of the elbow 
against the wall ; probably the hand was completely pronated. When 
seen, immediately after the accident, the head of the radius lay just under 
the skin behind the external condyle, where it formed a distinct projec- 
tion, revealing to the eye its characteristic shape with the cavity on its 
extremity. The hand and forearm were prone ; all movements were 
painful, and gave the impression of considerable fixity of the joint. Pain 
at the wrist led to an examination, which showed that "the styloid 
extremity was also dislocated downward, exactly as in cases in which the 
radius is shortened by the common fracture of its lower extremity.". 

While the character of the force and the direction of its action in this 
case are clear, pressure exerted against the lower end of the radius in 
the line of its long axis, yet it is far from being clear how such a force, 
so applied, could produce such a displacement. The skeleton shows that 
in this position the head of the radius is squarely placed against the 
anterior face of the capitellum, not upon an inclined surface along 
which it could be displaced. And yet, that there is something in the 
anatomical structure of the joint which favors the occurrence and forbids 
the rejection of the case on the supposition of abnormal conditions, is 
indicated by the fact that two similar cases have been reported by 
Wagner, 2 in which the mode of production was the same as in Cameron's, 
but the head of the radius was displaced to the outer side of the condyle 
instead of behind it, and a flat, wedge-shaped piece representing one-sixth 
of its diameter was broken off its inner side in one case. 

Streubel, 3 in his experiments upon the cadaver, found that he could 
produce the dislocation in only one way, by hyperextending the supinated 
forearm until the head of the radius had been carried completely behind 
the line of the condyle, then forcing it upward, and at the same time 
bending it to the radial side, and finally flexing it again while holding 
the radius pressed firmly back with the thumb of the hand that grasped 
the forearm. It is by no means probable that this rather complicated 
manoeuvre, which, moreover, has entirely failed in my hands, is a repro- 
duction of what has taken place in the falls that have produced the dis- 
location. The radius is dislocated not only from the humerus, but also 

1 Cameron : Lancet, 1884, i. p. 885. 

2 "Wagner : Beilage zum Centralblatt fur Chirurgie, 1886, No. 24, p. 93. 

3 Streubel : Prager Vierteljahrschrift, 1850, 2, p. 68. 



326 DISLOCATIONS AT THE ELBOW. 

from the ulna, and this requires the rupture of the orbicular ligament. 
To effect that, something more is required than hyperextension of the 
elbow, even with the addition of direct propulsion upward of the radius. 
Supination of the forearm, in which many have sought the explanation, 
will not effect it, for the movement is almost a pure rotation of the head 
about its centre, and is not arrested at its normal limits by the orbicular 
ligament. Direct propulsion backward of the bone would undoubtedly 
produce the dislocation, but the clinical facts do not indicate this as the 
cause. Possibly in hyperextension and outward lateral flexion, as in 
Streubel's experiments, the head of the radius may become engaged 
behind the slight projection of the articular surface of the capitellum at 
the bottom of the condyle, and be thereby prevented from accompanying 
the ulna in its return forward when the elbow is again flexed; this 
would supply the strain necessary to separate the radius from the ulna, 
but I must add that all the attempts I have made thus to produce the 
dislocation were fruitless; the result was always a dislocation of both bones. 

Barros 1 produced the dislocation experimentally in the bodies of 
young children and women in two ways : occasionally by direct violence 
upon the front of the head, although this usually caused a fracture; 
and, secondly, by traction upon the pronated hand, followed by forcible 
flexion. He found that rupture of the posterior segment of the external 
lateral ligament was an essential preliminary : if this was cut, simple 
extension (traction ?) at the pronated hand was sufficient. He usually 
found the orbicular ligament only partly torn. 

The anatomical obstacles in the way of such a dislocation of the 
radius that its head should lie, in the extended position of the elbow, 
against the back of the external condyle — that is, should be displaced 
upward as well as backward — are such that some writers, notably Dr, 
Markoe, 2 have maintained that it was possible only when associated with 
fracture of the internal condyle of the humerus or of the shaft of the 
ulna, or with rupture of the ligaments of the lower radio-ulnar joint, or 
with extreme lateral flexion of the elbow. Of these conditions, all 
except the last one have been observed clinically. But the records show 
that the dislocation may be simply backward, and not at all upward, a 
condition to which the above objection does not apply. There are no 
post-mortem records of recent cases, and the dissection of those of long 
standing is not an entirely trustworthy indication of the condition and 
the relations of the parts when the injury is fresh. A case observed by 
Mr. Rivington 3 is of particular importance, because the position of the 
head is more exactly noted than is usual in the descriptions. The 
patient was a lad, fourteen years old, and the injury had been received 
five months previously in a scuffle, during which he was violently shaken 
by the forearm, and thrown down, striking his elbow against the leg of a 
table. There was a marked prominence " at the back of the joint below 
the external condyle, and by the side of the olecranon process." " The 

1 Barros : Contribution a Tetude des luxations de 1' extremite superieure du 
Radius. Geneve, 1886. Abstract in Centralblatt far Chirurgie, 1886, p. 718. 

2 Markoe: N. Y. Journ. of Med. 1855, p. 382, and N. Y. Med. Record, 1880, vol. 
18, p. 118. See also Fractures, p. 398. 

3 Rivington: Lancet, 1879, ii., p. 942. 



DISLOCATIONS OF THE RADIUS ALONE 



327 



head of the radius was displaced more directly backward than is usual, 
according to the descriptions of the books, not lying in any wise behind 
the external condyle, but a little overlapping the articular end of the 
humerus." Flexion and extension were almost unimpaired, pronation was 
good, and supination to more than half the usual extent. Reduction failed. 

Mr. Rivington refers briefly to two specimens known to him, in both 
of which " the head of the radius has contracted new connections. In 
the one in the St. George's Hospital Museum, the new attachments 
formed by the ends of the orbicular ligament with the humerus prevented 
pronation and supination." 

It does not seem possible that the head of the radius in his case could 
have remained ''behind the articular end of the humerus" in full flexion, 
and the persistence of the displacement must, therefore, be attributed to 
the formation of new attachments by the torn orbicular ligament. 

In a specimen of an old dislocation, that had been received in childhood and 
had existed for many years, presented by Petit 1 to the Societe Anatomique 
the head of the radius was directly below the summit of the epicondyle 
when the elbow was flexed at a right angle. There was much overgrowth 
of bone on the trochlea, olecranon, and epicondyle ; the capitellum had 
been absorbed. Flexion and extension were rather limited ; rotation was 
preserved. In another specimen found in the dissecting-room and de- 
scribed and figured by Sir Astley Cooper, " the head of the radius could 
be seen, as well as felt, behind the external condyle of the os humeri. 
The coronary ligament was torn through at its fore part, and the oblique 
had given way. The capsular ligament was partially torn, and the head 
of the radius would have receded still more, had it not been supported by 
the fascia which extends over the muscles of the forearm." The accom- 
panying figure (Fig. 88) indicates that the head 
of the radius had risen very slightly above the 
lowest part of the articular portion of the condyle, 
and that its position was probably the same as in 
Mr. Rivington's case. In two cases quoted by 
Cooper from Langenbeck "the head of the radius 
was found thrown a little backward and outward 
from the external condyle of the humerus and 
could not be immediately detected." 

In another specimen of old dislocation pre- 
sented to the Societe de Chirurgie by Bernadet, 2 
the head of the radius had been displaced a little 
backward, downward, and outward ; the external 
lateral ligament entirely covered the cup-shaped 
surface of the head ; the annular ligament no longer 
existed except upon the inner side, and there it 
was notably thickened and obliquely deviated. 

In the specimens which Streubel obtained by 
experiment he always found the anterior portion 
of the capsule torn and the capitellum projecting 
through the rent ; the external lateral ligament 



Fig. 




Dislocation of the head of 
adius backward. (Cooper.) 



Petit: Bull, de la Societe Anatomique, 1874, p. 904. 
Bernadet: Bull, de la Soc. de Chir., 1861, p. 462. 



328 DISLOCATIONS AT THE ELBOW. 

was more or less torn at its anterior border, the internal lateral ligament 
uninjured; the annular ligament was always torn in front, either at its 
insertion by the lower sigmoid cavity, or further outward ; the oblique 
ligament was torn, doubtless in consequence of the exaggerated supination. 

These facts, though not numerous or entirely free from objection, 
indicate that the position of the dislocated head of the radius, even in 
full extension, is lower than that commonly assigned to it in the system- 
atic descriptions and shown in the plates accompanying them, that it 
does not rise above the shallow groove which marks the posterior and 
lower margin of the articular surface of the capitellum. At this point the 
upper margin of its head would be but very little below the axis of the 
joint, and consequently would have to move over only a short distance in 
full flexion and extension of the limb. 

In recent cases the elbow is slightty flexed, the forearm pronated ; 
voluntary and communicated movements are painful and limited in range, 
but in old cases the freedom of motion is almost completely restored, 
supination remaining the most imperfect. The diagnosis is made by 
recognition of the head of the radius behind its normal place in exten- 
sion, behind and below it in flexion at a right angle. It may lie close 
beside the olecranon or further to the outer side. Its projection, unless 
the swelling is considerable, is such that the entire extent of its concave 
upper surface can be felt. Measurement of the radial border of the fore- 
arm, from the epicondyle to the styloid process of the radius, may show 
some shortening, half an inch according to Streubel. 

Treatment. — The dislocation in recent cases has usually been reduced 
promptly by pressure on the head of the radius, aided or not by traction 
upon the wrist, and this method has succeeded even when several weeks 
had passed since the receipt of the injury. But in some cases reduction 
has been impossible or the displacement has shown a marked tendency to 
recur, both circumstances being probably due in the recent cases to the 
interposition of a portion of the capsule, but in the older ones also to 
permanent change in the relations of the shafts of the radius and ulna 
and to adhesions between them. This interposition of the capsule has 
been demonstrated in one or two cases in which arthrotomy has been 
done (see Chapter XXI.). Probably the best position to give the limb 
during the attempt is that of supination and full extension, and if direct 
pressure does not then restore the bone to its place traction should be 
made at the wrist, and the forearm gradually bent to the inner side, and 
then the direct pressure renewed. 

2. Dislocation of the radius outward. — Excluding the cases in which 
the dislocation is accompanied by fracture of the ulna in its upper portion 
and those in which the displacement outward is comparatively slight and 
is associated with a more important displacement backward or forward, 
the recorded instances of this injury are very few, and in some of these, 
even, the description justifies a doubt whether they should not rather be 
placed in one of the two other classes. 

Thomassin reported two cases to the Academie de Chirurgie in 1776, 
and Chedieu a third in 1805, which are quoted by Malgaigne, loc. cit., 
p. 668. In the former "the head of the radius projected at the top of 
the convex border of the forearm, pressing outward the mass of the supi- 



DISLOCATIONS OF THE EADIUS ALONE. 



329 



nator and radial (extensores radiales) muscles which cover it ; it was 
separated from the ulna, and a gap between the two could be easily 
recognized." In Chedieu's " the head of the radius projected at the 
outer and upper part of the forearm, rising higher than the external con- 
dyle, and pushing away the portion of the radials which there covers it." 
The position of the head which these descriptions indicate is such, I 
think, as would justify placing them in the class of dislocations forward, 
in which the radius passes upward in front of the humerus. 

In Nelaton's 1 case the dislocation occurred in childhood, as was also 
the case with the preceding three, and had existed for twenty years ; the 
position of the radius is shown in Fig. 

89. Flexion and extension were pre- Fig. 89 - 

served ; supination was impossible. 

Gerdy 2 briefly reported a case which 
he had seen some time previously and 
of which he had preserved no notes ; 
the patient was a man, and the disloca- 
tion was old. "The head of the radius 
projected considerably outside of the 
epicondyle." There was little or no 
limitation of the movements of the 
joint. 

Dr. Willard Parker 3 saw a child 
which, six weeks before, had fallen 
down stairs "with the right arm twisted 
behind the back in such a position that 
the whole weight of her body came upon 
her arm. ? ' The head of the radius pro- 
jected externally and could be easily 
reduced by pressure, but the displace- 
ment immediately recurred when the 
pressure was renewed and the forearm 
was flexed or extended. The move- 
ments of the joint were free. 

Yon Pitha 4 saw a case in a girl, nine 
years old ; the injury was caused by a 
maid servant who stepped with her heel 
upon the elbow while the child was 
sleeping on the floor with her arm ex- 
tended and supinated. The head of the radius lay upon the outer surface 
of the condyle. 

Broca's 5 patient was a girl, eleven years old, and the dislocation had 
existed fifteen months. The head of the radius lay immediately under 




Dislocation of the head of the radius out- 
ward ; the trochlea is much broadened. 
(■N£laton.) 



1 Nelaton : Pathol. Chirurgicale, vol. 2, p. 400. 

2 Gerdy: Archives gen. de Med., 1835, vol. 7, p. 161. 

3 Parker: N. Y. Journ. of Med., 1852, p. 189. 

* Pitha and Billroth : Chirurgie, vol. 4, Part 2, B, p. 92. 

5 Beported in a thesis by Boularan, Paris, 1875, and quoted by Pingaud and 
Poinsot. 



330 DISLOCATIONS AT THE ELBOW. 

the skin and could be grasped by the fingers and freely moved forward, 
backward, or outward. 

Wagner 1 reported to the German Surgical Congress, in 1886, three 
cases of dislocation outward complicated by fracture of the inner portion 
of the head of the radius. In the first two cases the injury was caused 
by pressure against the back of the flexed elbow while the palm of the 
hand was resting against a firm object in front. Thus, a lad, eighteen 
years old, pushing a coal-wagon on a tramway with his forearm pronated 
and flexed, was struck on the elbow by another wagon coming up from 
behind. A year had elapsed since the accident when the first case was 
seen, during which the joint had been steadily growing stiffer. The 
elbow was flexed at a right angle ; flexion, extension, and rotation were 
almost entirely lost. On the outer side of the external condyle was a 
large bony prominence, the thickened and immovable head of the radius ; 
there were no abnormalities in the other parts of the joint, and no sign 
of a fracture of the ulna. The head of the radius was excised ; it was 
found thickly enveloped in fibrous tissue, to which the appearance of 
thickening was due, and had lost from its inner side a flat, wedge-shaped 
piece constituting about one-sixth of its diameter. The fragment was 
found adherent to ' the capsule and was also removed. Recovery took 
place without accident, and the mobility of the joint steadily increased 
for some time. At the time of the report, nine years later, flexion could 
be made to an angle of 80°, extension to 150°, pronation was almost 
normal, supination somewhat restricted. 

In the second case, a man twenty-six years old, was injured in the 
same manner, and was seen while the injury was fresh. Passive flexion 
and extension were possible, but painful; the forearm was completely pro- 
nated, and could not be supinated. The region of the joint was much 
swollen on the outer side, normal on the inner side. Examination under 
anaesthesia showed the head of the radius outside the external condyle, 
and keeping its position during flexion and extension ; a flat, wedge- 
shaped loss of substance could be recognized by the touch on the side 
adjoining the capitellum, more distinctly when the limb was supinated. 
No fracture or other abnormality could be found in the ulna or in the 
other parts of the joint. 

Reduction was effected, after several unsuccessful attempts, by, first, 
adduction of the flexed limb, then by the utmost possible abduction, with 
supination, of the completely extended limb, combined with pressure 
upon the head of the radius. When the dressings were removed, a month 
later, passive movements were very painful and limited, and, as no 
improvement followed, excision was done five months after the accident. 
The head of the radius was found thickened and absolutely fixed, and 
the fragment reunited to it by a loose fibrous union ; the failure of union 
was attributed to the interposition of a small piece of the articular carti- 
lage. Recovery followed without accident, but the mobility of the joint 
was not increased. 

In the third case the patient had received his injury twenty-two years 
before, when six years old, by a fall from a horse. " The head of the 

1 Wagner : Beilage zum Centralblatt fur Chir., 1886, No. 24, p. 93. 



DISLOCATIONS OF THE RADIUS ALONE. 331 

radius stood outside upon the external condyle," and was flattened on its 
inner side ; there was no sign of any injury to the ulna. The move- 
ments of the joint were completely normal. 

Looker, 1 in a paper read before the same congress, reported two cases 
of the same combination of dislocation outward with fracture of the inner 
portion of the head of the radius treated by excision. In each case the 
fragment had become united to the adjoining parts by a pedicle. 

Bart els 2 reported a unique case in which the heads of both radii had 
gradually become displaced outward. The patient was a man forty -three 
years old, who, while lying in hospital with a broken leg, called the 
surgeon's attention to his elbows. He said that the deformity dated from 
his eleventh year ; his father had at that time put him at hard work, 
usually pushing a loaded cart ; pain was soon felt in the elbows, and 
increased steadily, but he was kept at work. The head of the radius 
rested on the outer side of the external condyle when the limb was fully 
extended and supinated ; when extended and pronated, the head was less 
prominent, and rested partly on the outer part of the articular surface of 
the capitellurn, and when flexed and pronated the head returned to its 
place. 

Barros could produce the dislocation experimentally in only one way, 
by pressure against the ball of the hand, and simultaneous forcible adduc- 
tion of the forearm, by which the external lateral ligament was torn. 

The general symptoms in the recent cases showed no special or charac- 
teristic features ; the limb appears to have been partly flexed and pronated, 
and the movements of the joint restricted. In the older cases, the normal 
movements were more or less completely reestablished. 

In both of Thomassin's and in Broca's cases the dislocation was reduced 
without difficulty, but recurred repeatedly, and was finally abandoned. 
Chedieu failed to effect reduction a fortnight after the accident. In 
Sprengel's case of backward and outward dislocation, treated by arthro- 
tomy (see Chapter XXL), a portion of the capsule was found interposed. 

3. Dislocations forward. — These are the most common of the three 
varieties, even excluding from them the not unusual subluxation which 
occurs in children and will be described in the next section. The dislo- 
cation is characterized by the position of the head of the radius in front 
of its normal position when the forearm is extended, and above it when 
the forearm is flexed at a right angle. Several authors describe two 
forms, the complete and the incomplete, including in the latter those cases 
in which in flexion at a right angle the head of the radius has not entirely 
left the articular surface of the capitellurn, but remains in contact with 
its upper portion. Malgaigne also includes in the incomplete variety the 
subluxations or " dislocations by elongation " in children. The distinction 
between complete and incomplete is an arbitrary one and does not 
seem to deserve to be retained, for even in the former the head of the 
radius sometimes descends upon the articular surface of the capitellurn 
when the limb is extended. 

The causes mentioned in the reported cases include falls upon the hand 

1 Lobker, Idem, p. 92. 

2 Bartels: Archiv fur klin. Chir.,1874, vol. 16, p. 643. 



332 DISLOCATIONS AT THE ELBOW. 

or upon the elbow, and traction upon the forearm. In experiments upon 
the cadaver the dislocation has been produced by forced pronation, in 
which, according to Filugelli, quoted by Streubel, a fulcrum is established 
by contact between the radius and ulna in their upper third at the point 
at which they cross, the effect of which is to cause the head of the radius 
to move forward and inward, with rupture of the anterior portion of the 
annular ligament when the pronation is exaggerated. 

As in the two preceding varieties, the mode of production is far from 
clear. That the head should be displaced by direct violence is not diffi- 
cult to comprehend, but the cases in which this mode of production can 
be invoked are few. Traction upon the forearm, combined probably with 
exaggerated pronation, must also, I think, be admitted as an occasional 
cause, especially in children, both because of its efficiency to produce the 
dislocation upon the cadaver, and because the histories of one or two cases 
in adults are not open to any other explanation, as in Boyer's case of the 
footman who slipped while getting up behind a carriage, and remained 
suspended by his hands. It seems probable that some of the cases in 
which the injury was received in childhood, and remained unreduced, may 
have been dislocations by elongation, and that the head remained fixed 
in its new position, or perhaps was still further displaced by use. In a 
fall upon the hand, it seems probable that the dislocation could be pro- 
duced only by hyperextension and pressure upon the lower end of the 
radius, aided by supination or pronation, and this opinion is confirmed 
by experiment. A case of Malgaigne's (loc. cit., p. 651) seems to support 
this theory, for at the patient's death, seven weeks after the accident, the 
posterior fourth of the head of the radius was proved to have been broken 
off. In two of Lobker's cases (loc. cit., p. 92) a piece was broken from 
the outer portion of the head, which suggests, what is probable also on 
other grounds, that abduction of the forearm may also be a factor. 

In a case reported by Ross (Streubel, loc. cit., p. 75) the dislocation 
occurred during an epileptic convulsion and was attributed to muscular 
action, the unopposed contraction of the biceps and pronator radii teres. 

Pathology. — No autopsies have been reported in recent cases. In 

Fig. 90. 




Hilton's case of dislocation of the head of the radius forward. 

experiments upon the cadaver (Streubel, Pingaud) the capsule has been 
found torn transversely in front close to its attachment to the humerus 
(Fig. 90), and the annular ligament untorn and encircling only the neck 
of the radius while the head projected forward through the rent in the 
capsule and rested, by its posterior edge only, against the articular surface 
of the capitellum. 



DISLOCATIONS OF THE RADIUS ALONE. 333 

In a number of cases, ten or twelve, the opportunity has arisen to 
examine old dislocations. Malgaigne has described his own, quoted 
above, in which the posterior fourth of the head of the radius was broken 
off and the capsule was intact, and two specimens in the Musee Dupuy- 
tren (cases of Desault and Prestat). Cooper (loc. cit., p. 392) describes 
and figures a specimen preserved at St. Thomas's Hospital : Danyau, 1 
Debruyn, 2 two cases, Hilton, 3 Trelat 4 , Kronlein, 5 a specimen in the 
Museum at Zurich, and Lobker the two cases above referred to. 

In Malgaigne's, Danyau's one of Debruyn's, Trelat's and the two speci- 
mens of the Musee Dupuytren the annular ligament was stretched but 
not torn ; in Hilton's its upper portion was torn but the more external 
and superficial fibres remained intact and were closely wrapped about the 
neck of the radius ; in Cooper's the annular, oblique, forepart of the 
capsular, and a portion of the interosseous ligament were torn through. 
With reference to some of these cases the question has been raised 
whether the annular ligament found at the autopsy was not one of new 
formation. 

The head of the radius rests, in partial flexion, upon the anterior sur- 
face of the external condyle above and usually somewhat to the inner 
side of its normal position, and either in contact with the coronoid process 
or (Hilton) separated from it by the interposed tendon of the brachialis 
anticus. In three cases (Malgaigne, Lobker) a piece had been broken 
from its posterior or outer border. In several of the cases a hollow had 
formed for its reception on the anterior surface of the humerus ; the new 
articulation was either entirely above the old one, or included the upper 
part of the capitellum, or (Trelat) extended over the outer portion of the 
front of the trochlea. The head of the radius was deformed and had 
suffered the loss of more or less of its cartilage of incrustation ; in some 
cases it was enlarged, in others diminished in size. In Kronlein's speci- 
men an extensive outgrowth of bone had formed upon the inner side, 
giving the upper end of the bone an appearance similar to that of the 
upper end of the femur, and articulating with a new cavity upon the 
humerus ; it is stated that the movements of rotation had been ■ com- 
pletely restored. 

An interesting feature in Hilton's case was that the radius had been 
displaced bodily upward along the ulna, and this displacement had pro- 
duced changes at the wrist ; there was an aperture in the articular fibro- 
cartilage uniting the radius and ulna, the semilunar and pyramidal bones 
had lost some of their articular cartilage, and the former had undergone 
a marked change in shape. 

Malgaigne observed and called especial attention to abduction of the 
forearm, which does not appear to have been observed by others. It 
furnishes a satisfactory explanation of the displacement of the radius 
upward as well as forward, which could not otherwise be accounted for 
except by such a change in the level of the bones at the wrist as was 

1 Danyau : Annales de la Chir. Frangaise et Etrangere, 1841, vol. 2. p. 72. 

2 Debruyn : Annales de la Chir. Frangaise et Etrangere. 1843, vol. 9, p. 88. 

3 Hilton : Guy's Hosp. Eeports, 1847, vol. 5, p. 93. 

4 Trelat : Bull, de la Societe Anatomique, 1858, p. 487. 

5 Kronlein : Deutsche Chirurgie, Lief. 26, p. 44. 



334 DISLOCATIONS AT THE ELBOW. 

noted in Hilton's case. Abduction of the forearm might easily be over- 
looked while the joint is partly flexed unless comparative measurements 
are made. 

Symptoms. — The elbow is slightly flexed and the forearm almost always 
more or less proriated ; in a few cases supination has been present. Volun- 
tary and communicated movements are painful, and of the latter flexion 
nearly to a right angle and almost complete extension are possible, prona- 
tion is usually complete, but supination much restricted. Abduction of the 
forearm has been noted, possibly it is quite common, and when present 
it can be demonstrated by comparative measurements of the radial 
borders of the two forearms, the injured one being shortened. The region 
of the elbow is swollen in front and on the outer side ; the absence of the 
head of the radius from its normal position is shown by the depressibility 
of the soft parts on the outer side of the joint below the condyle, and its 
presence in the fold of the elboAV can generally be recognized by the 
finger ; sometimes it is so prominent there that it appears to be subcu- 
taneous, and the saucer-like depression of its upper surface can be traced 
when the joint is extended. Flexion of the forearm is abruptly arrested 
at or near a right angle by the impact of the head of the radius upon the 
front of the humerus, and this is sometimes accompanied by a shock or 
blow distinctly perceptible by the surgeon. 

In the older cases the restoration of function may be almost complete, 
the range of motion being limited only in extreme flexion and supination. 

In Hilton's case the associated changes at the wrist caused a corre- 
sponding deformity there, abduction of the hand ; and it seems not 
unlikely that even in some recent cases the wrist may be painful or dis- 
torted. This coincidence has been noted in cases of dislocation by 
elongation in which subluxation forward of the head of the radius was 
demonstrated. 

Treatment. — Reduction has been easy in some recent cases, and diffi- 
cult or impossible in others. The measures which have been most suc- 
cessful are traction upon the radius at the wrist, the forearm being supi- 
nated and extended, combined with pressure upon the head of the radius. 
Malgaigne suggests, very properly, that adduction of the forearm would 
be more likely than traction to overcome the overriding of the radius. 
Hilton reduced the displacement in his specimen, which had existed for 
many years, by placing a small wedge between the upper surface of the 
radius and the humerus, and then flexing the forearm by pressing upon 
the lower end of the ulna; when flexion was nearly complete direct 
pressure upon the head of the radius forced it backward into place. The 
effect of this device was to displace the radius downward along the ulna 
to a distance equal to the thickness of the wedge, and to rupture the liga- 
ments which bound the two bones together. Possibly it would be prudent 
to employ it upon the living patient in more recent cases in which a dis- 
placement of the radius upward along the ulna could be demonstrated. 
A marked tendency to recurrence has been frequently noticed, and has 
generally been attributed to interposition of a portion of the capsule. I 
am inclined to think it due, in some cases at least, to the persistence of 
this bodily displacement of the radius upward. If so, the condition would 
be shown, after reduction, by loss of the outward inclination of the fore- 



DISLOCATIONS OF THE RADIUS ALONE. 335 

arm in full extension, and the effort should be made to overcome it by 
restoring this angle by forcible abduction. 

The position of the rent in the anterior portion of the capsule suggests 
that after reduction the joint should be kept flexed, and although recur- 
rence of the dislocation has taken place with the limb in this position, it 
does not seem so likely to favor such recurrence as the extended position. 

4. Dislocation by elongation, or the subluxation of young children. — 
Under these names is described an injury which is very frequently 
observed, but the nature of which, after nearly two centuries of discussion, 
is still in dispute. Its features are well marked ; a young child, generally 
less than three years old, is lifted or pulled by the hand; it cries out with 
pain, and refuses to use the limb, which hangs motionless by the side, 
somewhat flexed at the elbow, and more or less pronated. A careful 
examination fails to discover marked change in the anatomical relations 
of the bones at the elbow or wrist ; passive motion at both joints is free, 
but painful, except supination, which is resisted ; often during the 
manipulations made in the examination, or on forced supination, a slight 
click is heard, and the child at once is able to use the limb freely without 
pain. 

The history of the views that have been held concerning the nature of 
the affection was written by Malgaigne in 1843, and repeated in his work 
on dislocations, and his account has been quoted by several systematic 
writers on the subject, notably Streubel and Pingaud, and was continued 
to date, in 1861, by Goyrand, 1 who then presented a new theory, and 
although the injury was fully described by Gardner 2 in 1837, and by 
Hodges 3 in 1862, yet it is still so little known in England and the United 
States that cases are reported from time to time in the journals as rari- 
ties, it is usually passed by without mention in the text-books, and as 
recently as 1885, Mr. J. Hutchinson, Jr., 4 of London, published an 
account of it, in which he quoted Mr. Christopher Heath as authority 
for the statement that it was made known in England by McNab in 1862, 
and he offered as a discovery an explanation which was given by Duverney 
in 1751, had been discussed and rejected by Goyrand 5 in 1837, elabo- 
rately studied and accepted by Pingaud 6 in 1878, quoted and accepted 
by Poinsot in 1884, and discussed by Hamilton, 7 with a translation of 
Poinsot's article in 1885. It will be sufficient to trace merely the out- 
lines of this history, and only so far as to bring out the theories that need 
to be considered. 

As early as 1671 Fournier described the injury as an incomplete 
dislocation characterized by relaxation of the ligaments and elongation of 
the radius, meaning by the latter direct separation downward or diastasis. 
Nearly a hundred years later, Duverney 8 gave a clear and exact descrip- 

1 Goyrand : Bull, de la Societe de Chiruro;ie, 1861, p. 605. 

2 Gardner : London Medical Gazette. 1837, vol. 20, p. 878. 

3 Hodges : Boston Medical and Surgical Journal, 1862, vol. 67, p. 129. 

4 Hutchinson, Jr.: Annals of Surgery, August, 1885, and British Medical Jour- 
nal, 1886, i. p. 9. 

5 Goyrand: Gazette medicale de Paris, 1837, p. 115. 

6 Pingaud: Diet, encyclopedique. art. Coude, p. 580. 

7 Hamilton : New York Medical Journal, Jan. 3, 1885, p. 8. 

8 Duverney: Maladies des Os, 1751. 



336 DISLOCATIONS AT THE ELBOW. 

tion of it as an injury occurring frequently in children ; he attributed it to 
forcible traction at the wrist, and gave as its chief symptom the opposition 
to supination of the forearm, and as the treatment forcible supination 
with pressure from before backward upon the head of the radius followed 
by flexion of the elbow. He thought the injury was not merely an 
elongation of the radius, but also the escape of its head below the edge 
of the orbicular ligament. Nearly a century and a half has passed since 
the publication of his views, and but little has been added to his descrip- 
tion of the etiology, symptoms, or treatment, and while the years have 
brought many other theories concerning the pathology his is the one that 
is now most widely held. 

In 1787 Bottentuit presided at the presentation, and, according to 
Malgaigne, was probably the real author, of a thesis by Bouley before 
the Ecoles de Chirurgie, 1 in which the theory of the agency of forced 
pronation in the production of the injury was advanced ; it was argued 
that in this movement the radius and ulna came into contact at the point 
where they crossed each other near the elbow, and that, the movement 
being continued, the head of the radius was displaced forward or outward. 

At the beginning of the present century Martin, in France, 1809, and 
Monteggia, in Italy, 1814, described the injury and reported cases, but 
the former, unfortunately, appears to have encountered also some dislo- 
cations backward, and he not only included them in the same group, 
but he also thought that the radius was dislocated backward in all, and 
this opinion has survived in a measure until the present time, and has led 
systematic writers to describe a dislocation backward as one of the forms, 
although it does not appear that there is any other authority for the 
statement than Martin. 

As the injury is one that seems but rarely to fall under the observation 
of the general surgeon, probably because of the facility with which it is 
reduced, the authors of the surgical text-books either made no mention 
of it or followed in their brief descriptions the account given by Martin, 
or by those who had copied from him. But between 1836 and 1850 
several cases were published in England and in France, and new theories 
concerning its nature were advanced. Gardner in 1837 (ut supra), and 
Rendu 2 in 1841, attributed the fixation to the locking of the bicipital 
tuberosity behind the ulna, but the latter, who in two cases had made the 
important observation that the wrist also was swollen and tender, added 
to this supposed locking of the tuberosity which he regarded as probably 
exceptional, a rupture of the ligaments of the wrist. Perrin, 3 in 1849, 
thought the head of the radius was caught below the lower edge of the 
lesser sigmoid cavity, and Goyrand, who saw a large number of cases, 
thought the lesion was an incomplete dislocation, in which the displace- 
ment was so slight as to cause no recognizable deformity at the elbow. 
Malgaigne, 1854, included it among the incomplete dislocations forward, 
and others did likewise. 

In 1850, Streubel 4 made the theory of incomplete luxation more 



1 Bouley: De radii superioris extremitatis dimotione, in infantibus frequentiori. 

2 Kendu: Gazette medicale, 1841, p. 301. 

3 Perrin : Journ. de chirurgie de Malgaigne, vol. 5, p. 145. 
* Streubel : Prager Vierteljahrschrift, 1850, ii. p. 90. 



DISLOCATIONS OF THE RADIUS ALONE. 387 

definite, by showing that if the forearm of the cadaver of a young child 
was forcibly pronated, the head of the radius moved forward, and the 
posterior portion of the capsule was forced in by atmospheric pressure 
between the radius and the capitellum, and that if then the pronation 
was diminished, the slight displacement of the radius and the interposi- 
tion of the capsule would persist even while gentle movements of the joint 
were made ; but that under sudden extension and supination the normal 
relations would be established. In like manner, forced supination would 
displace the radius backward, and lead to interposition of the anterior 
portion of the capsule. In the bodies of adults, neither manipulation 
would produce this result. 

In 1856, Chassaignac 1 described, under the title " paralysie doidou- 
reuse des jeunes enfants" a number of cases of the injury under discus- 
sion, together with others of a different nature, and attributed the 
symptoms in all to injury of the nerves of the limb. Finally, in 1861, 
Goyrand 2 returned to the subject in a lengthy paper, in which he aban- 
doned his previous view and advanced the last new theory, that the lesion 
was situated not at the elbow, but exclusively at the wrist, and consisted 
in a dislocation of the triangular fibro-cartilage in front of the lower end 
of the ulna. His experiments showed that in complete pronation the 
fibro-cartilage was carried so far forward as almost entirely to uncover 
the end of the ulna, and that in forced pronation the uncovering became 
complete. In reply to a question asked by Velpeau, he admitted that the 
displacement did not persist upon the cadaver unless the hand was held 
upward and supinated, but he thought that the tonic contraction of the 
muscles in the living would maintain it. He did not explain why such a 
lesion should be more easily produced in a child than in an adult. 

It may be worth while to add that the editor of the Medico- Qhirurgical 
Hevieiv, in 1839, thought the injury was a separation of the upper epi- 
physis of the radius, and Fougeu, 1861, a separation of the lower one. 

Pingaud (loc. cit., 1878), in his experiments upon the cadaver, found, 
as Goyrand had similarly clone in 1837, that the head of the radius could 
be drawn out through the orbicular ligament by forcible adduction of the 
forearm, so far that its anterior edge -would engage below the lower border 
of the ligament (Fig. 91), and the bones would remain separated by a 
distance of about a quarter of an inch, but without displacement of the 
radius forward, backward, or outward, unless forced pronation w T as added 
to the adduction, in which case the head moved forward ; and as this 
condition of the parts coincided with a limitation of the freedom of rota- 
tion of the forearm similar to that observed clinically in the cases in 
question, and as the normal relations of the parts were restored by the 
same manoeuvres which relieved the little patients, he reached the con- 
clusion that the nature of the lesion observed clinically was the same as 
that which he had produced experimentally, and that the clinical injury 
was, therefore, a dislocation of the radius downward below the annular 
ligament, or, in other words, that Duverney's theory was the correct one. 
He showed further, that the younger the child the more easily could this 

1 Chassaignac: Archives generales de Med., 1856, i. p. 653. 

2 Goyrand : Bull, de la Societe de Chir., 1861, p. 596. 

22 



338 



DISLOCATIONS AT THE ELBOW, 



displacement be effected, and the more complete, circularly, would it be. 
He would not assert that this was the only cause of the clinical condition, 
but contented himself with proving that it was at least one ; his reserve 
being apparently due to the inapplicability of the explanation to the 
reported cases in which the radius was said to have been displaced back- 
ward, cases which we have seen to rest only upon Martin's assertion. 

Fig. 91. 




Subluxation of the head of the radius. (Pingaud ) 



His experiments have been repeated, and his results verified by others ; 
Poinsot accepts his explanation fully for the usual cases, and Streubel's 
for those of displacement backward, but Hamilton (loc. cit.), while 
admitting it to be probably true of many, thought others were paralytic 
in nature, an opinion in support of which he offers no clinical proof. 

Turning now to the clinical evidence, for there have been no post- 
mortem examinations, it appears that the injury is common in young 
children between the ages of one and three years, and is rarely seen after 
the age of six years, and not infrequently recurs. Goyrand (loc. cit., 
1861) had seen at least two hundred cases in thirty years, and quotes 
Ohabrely (Journal de Medeeine de Bordeaux, October, 1860, p. 481) as 
saying that hardly a month passed, he might say hardly a week, in which 
he was not called to a case, and Fougeu as having seen thirty-five cases ; 
in the discussion that followed the reading of Goyrand's paper, Marjolin 
stated that he had seen about sixty cases. Snedden 1 saw ten cases in ten 
years in private practice ; and Lindeman 2 saw twenty-four cases in two 
years in dispensary practice. The cause is traction upon the arm at the 
hand or wrist, as in lifting a child, or in holding it when it stumbles, and 
in two cases in drawing the arm through the sleeve of the dress. It 
seems to me that exaggerated pronation does not enter into the mechanism 
by which the lesion is produced, but that the violence is simply traction 
exerted upon the extended elbow, and possibly combined with adduction, 
for traction would tend to make the limb exactly straight, and thus over- 
come the normal inclination of the forearm outward ; or the grasp upon 
the forearm may be so firm that an actual inward inclination would be 

1 Snedden : British Med. Journal, 1882, i. p. 499. 

2 Lindeman: British Med. Journ., 1885, ii. p. 1058. 



DISLOCATIONS OF THE RADIUS ALONE. 339 

produced in case the effort was not a simple traction, but was combined 
with a movement that tended to swing the child upward along a curve, 
whose centre was its wrist, and whose radius was its extended arm. At 
least, in lifting a living child by the arm I have not been able to make 
exaggerated pronation, for rotation at the shoulder is so free that the limit 
of pronation is not easily reached, and this is unquestionably true when 
the child is lifted by both hands. 

The child at once cries out in pain and refuses to use the limb, which 
hangs motionless by its side, or is supported, with the elbow slightly 
flexed, across the front of the abdomen ; the wrist is completely or partly 
pronated. Examination shows sensitiveness at the outer portion of the 
elbow, in some cases also at the back of the wrist, and in others exclu- 
sively at the wrist, with swelling after the lapse of from thirty to thirty- 
six hours. The head of the radius is sometimes slightly but distinctly 
displaced forward, but in most cases no other change than a slight 
longitudinal separation between the radius and the capitellum is recog- 
nizable ; Marjolin said that in some of his cases he had found t; a slight 
deformity" at the elbow, and in all of them pain on pressure in front or 
on the outer side of the head of the radius. In seven of Snedden's cases 
the pain and local symptoms indicated the elbow as the seat of the injury; 
in the remaining three the wrist; in one patient it occurred twice at the 
wrist and once at the elbow, and in another three times at the elbow. 
In both of Rendu 's cases there was pain and swelling at the back of the 
wrist. 

Although the child does not voluntarily move the joint, it can be freely 
moved by the surgeon in every direction except supination, and will 
sometimes be held by the child in such a position as may be given to it. 
In only one recorded case, Duges, 1 was the limb in supination ; with 
that exception the constant and pathognomonic symptom is the inter- 
ference with supination. 

These facts, taken in connection with the results of experiment, indicate 
that Duverney's opinion was correct and that the injury consists in the 
escape of the front portion of the head of the radius below the orbicular 
ligament, and that it is produced by traction and adduction of the ex- 
tended forearm. Goyrand's last explanation — dislocation of the triangular 
fibro-cartilage at the wrist — cannot maintain itself against the over- 
whelming clinical evidence of the existence of a lesion at the elbow, 
supported, as it is, by experiment, especially since it has no better 
foundation than the impression that the click which was heard during 
reduction was produced at the wrist and not at the elbow. Against its 
correctness are the facts that although exaggerated pronation will effect 
such a dislocation, yet there is nothing to prove that the displacement 
will not immediately correct itself when the limb is released, and that 
there is not only no proof of the intervention of exaggerated pronation in 
the clinical cases, but it was, furthermore, certainly absent in some, and 
probably in all. The only difficulty is to explain the well-established 
symptoms of injury at the back of the wrist in some of the cases. Pos- 
sibly such cases may be of a different character from the others, actual 

1 Duges: Journal hebdomadal re, 1831, vol. iv. p. 196. 



340 DISLOCATIONS AT THE ELBOW. 

dislocation backward of the lower end of the ulna (vide infra), and 
Goyrand's explanation may be true of them ; or the symptoms may be 
due to an associated sprain of the wrist. 

The experience of Chassaignac, who treated his cases as paralytic and 
saw them gradually recover, indicates that the lesion may be spontane- 
ously corrected; but, on the other hand, there is reason to think that 
some of the cases of forward dislocation of head of the radius found in 
adults, which had existed from childhood, were originally of this kind, 
and that the head had gradually become displaced further forward. All 
who have treated cases agree that reduction is easily effected, usually by 
supination ; some add flexion of the elbow. Hutchinson recommends 
pronation and flexion of the elbow. 

Dislocation of the Head of the Radius with Fractuee of 

the Ulna. 

The coincidence of a fracture of the shaft of the ulna with dislocation 
of the head of the radius is not infrequent, and since the discovery of 
either of the two injuries may lead the surgeon to overlook the other, the 
possibility of the coexistence should always be borne in mind. Malgaigne 
attached so much importance to this warning that he formulated and 
italicized the following tw T o recommendations : 

1. In any fracture of the ulna alone look for a dislocation of the radius. 

2. In every fracture of the forearm in which the swelling extends above 
the elbow, remember that simple fracture is rarely accompanied by so 
much swelling, and carefully explore the articulation. 

To complete the warning a third precaution should be added, namely, 
that in every dislocation of the head of the radius alone, fracture of the 
ulna should be sought for. 

The complication has received the attention of most systematic writers 
upon dislocations, and has been made the subject of monographs by Mal- 
gaigne, 1 Grenier, 2 and Ddrfler. 3 The latter collected nineteen cases, but 
the injury appears to be of more frequent occurrence than this fact would 
indicate, for Malgaigne saw four cases, von Pitha two or three, and 
Ddrfler reports four cases from the practice of the surgeon under whom 
he was serving. 

The cause in a certain number of cases — five of Dorfler's nineteen — 
has been direct violence, as the kick of a horse, received upon the inner 
or inner and posterior aspect of the upper part of the ulna, first breaking 
that bone and then driving the head of the radius forward and outward 
from its place: in others it has been a fall upon the arm, and it is un- 
certain whether the ulna was broken by direct or indirect violence. In 
Gerdy's case the patient declared that he fell upon his extended hand ; 
and in one that came under my care in August, 1885, the patient, a boy 

1 Malgaigne : Revue medico-chirurgicale, vol. xiii. pp. 82 and 90. 

2 Grenier : Recberches fur la luxation du radius que complique la fracture du tiers 
superieur du cubitus ; The-e de Paris, 1878. 

3 Ddrfler: Fractur der ulna in ihrem oberen Drittel combinirt mit Luxation des 
Radius; Deutsche Zeitschrift fur Chir., 1886, vol. xxiii. p. 338. 



DISLOCATION OF THE HEAD OF THE RADIUS. 341 

seven years old, had fallen from a wagon and sustained a compound 
fracture of the ulna at its middle, the wound in the skin being in the 
centre of the anterior aspect of the limb and having been produced from 
within outward by the sharp end of one of the fragments : the radius was 
displaced forward, upward, and inward so far that its concave upper 
surface could be distinctly felt. There was no bruise on the back of the 
forearm, and I thought the fracture had been produced by indirect vio- 
lence. Dorfler inferred from the results of his experiments that the 
fracture is the primary injury and is always produced by direct violence, 
and that the dislocation is secondarily produced either, and more 
frequently, by the continued action of the original force, or by a new, 
indirect violence. 

In ten of his nineteen cases the patients were from three to fifteen 
years old ; the remaining nine were from thirty -five to sixty-five years old. 

The only autopsical record I have found is one by Marchand, 1 and, 
unfortunately, it is not entirely clear. It is stated that the external 
lateral ligament was torn, the ulna was broken in its upper third, and the 
head of the radius was displaced to the outer side of the epicondyle ; the 
annular ligament was untorn, but " no longer surrounded the neck of the 
radius ; it seemed rather to embrace the radial capsule (cupule, head ?), 
and the radius seemed to have escaped below it." 

Dorfler's experiments showed that the parallelism of the radius and the 
lower fragment of the ulna was preserved, with production of an angle in 
the ulna at the point of the fracture ; the annular and the anterior liga- 
ments were torn. The limb was shortened, and crepitation was perceived 
on handling it. Clinically, a prominent feature is the marked swelling 
at the elbow, due in part to the displacement of the radius and in part to 
inflammatory reaction. The displacement of the radius is usually forward, 
sometimes forward and inward, forward and outward, or directly outward. 

Among the complications were observed subluxation of the lower end 
of the ulna, wound of the integument either by the direct action of the 
causative violence or from within outward by the end of the fragment, 
making the fracture compound, fracture of the epicondyle or external 
condyle, and more or less paralysis of the extensor muscles of the wrist 
and fingers due to stretching or rupture of the musculo-spiral or posterior 
interosseous nerve. 

The prognosis is good if the displacements are promptly corrected, and 
even if the dislocation of the radius persists the restoration of function 
may be nearly complete. Malgaigne mentions a case of such persistence 
after an injury received in childhood, in which extension and supination 
were complete, flexion almost complete, and pronation restricted about 
one-quarter ; the head of the radius had passed upward in front of the 
humerus by the aid of marked deviation of the forearm outward and by 
an absolute ascension along the ulna which was shown by the fact that 
the styloid processes of the two bones were on the same level. 

On the other hand, failure of union of the fracture has been noted 
(Norris 2 ), and persistent extensor paralysis (Dorfler). 

1 Marchand: Bull, de la Societe Anatomique, 1874, p. 680. 

2 Norris : Amer. Journ. Med. Sciences, vol. 31, p. 20. 



342 DISLOCATIONS AT THE ELBOW. 

Reduction in recent cases has been easy ; in my own the dislocation 
could be readily produced and reduced by pressure on the radius when 
the elbow was held at a right angle. The most suitable method of reduc- 
tion appears to be traction upon the extended limb, followed by direct 
pressure upon the radius and then by flexion of the elbow. The extended 
position during traction is desirable in order to avoid the interposition of 
the torn anterior ligament. After reduction the limb should be kept flexed 
within a right angle, and midway between supination and pronation. 









CHAPTEE XXI. 

dislocations of the elbow. — {Continued.) 

treatment of old dislocations. congenital and pathological 

dislocations. 

Treatment of Old Dislocations. 

The loss of mobility in old dislocations of the elbow, especially of the 
backward ones, is often so great that the disability is serious ; the patient 
is unable to bring the hand to the head or chest, and is able to use it only 
in the arc of a circle whose radius is nearly equal to the length of the 
extended limb, and he may, in addition, possess only such rotation as 
can be effected by movements at the shoulder. Although successful 
attempts to reduce dislocations of several months' standing were occa- 
sionally reported, yet failure was the rule, and the only means of allevi- 
ating the condition were fracture of the olecranon and excision of the 
joint, operations which, while they increased the range of motion, brought 
with them disadvantages of their own, such as loss of active extension 
and lack of solidity, which disinclined the surgeon to offer, and the patient 
to accept them. 

Consideration of the anatomo-pathological conditions of an old unreduced 
dislocation not only freely explains the difficulty of effecting reduction but 
even makes it appear surprising that reduction should ever have been 
satisfactorily accomplished. The overriding of the bones along the back 
of the humerus leads to the formation of new cicatricial bonds between 
the olecranon and the humerus and to the establishment of new attach- 
ments by the torn lateral ligaments so far above and behind the centre of 
motion of the old joint that almost no flexion is possible Avithout their 
rupture or elongation, and the return of the bones to their place can be 
effected only after a far more extensive rupture of these soft parts than 
that which accompanied the dislocation. In attempting to rupture these 
bonds by forced flexion the forearm is used as a lever the fulcrum of 
which is situated on the ulna below the coronoid process, and the ruptur- 
ing strain is exerted through the olecranon upon the ligaments and 
adhesions connected with it, and it is not to be wondered at that this 
process should so frequently have been broken in the manipulation. In 
addition, the greater sigmoid cavity very promptly fills with cicatricial 
tissue, partly of new formation and partly furnished by the upper part of 
the posterior portion of the capsule which slips in between it and the 
back of the humerus and permanently occupies the concavity which 
should, after reduction, embrace the trochlea ; this pad of tissue is found 
so firmly united to the cartilage of the olecranon that its removal in the 



344 DISLOCATIONS OF THE ELBOW. 

reported arthrotomies lias required the use of the knife. The adhesion 
of the capsule to the articular surface of the front of the trochlea and the 
capitellum has not been found to be so close, and the cartilage of their 
surfaces has been found, even after the lapse of several months, almost 
entirely unaltered in appearance. 

Furthermore, the injury is common in the young, in whom the osteo- 
genic power of the periosteum is great and in whom the epiphyses are 
still growing. The effect of the injury, especially if the periosteum is 
stripped up, is, therefore, to produce new formations of bone around the 
joint which contract adhesions with the other bones or mechanically interfere 
by interposition to prevent the reduction of the dislocation ; and, further, 
the epiphysis of the humerus, relieved of the pressure normally exerted 
upon it by the radius and ulna, grows more rapidly and irregularly, and 
its articular surface may thus lose its shape and become unfit to receive 
the others again. This deformity, by exaggerated growth has been 
especially noticed in the capitellum (see pathological and congenital dis- 
locations), the extension being downward and fonvard. In a specimen 
shown by Dr. Lange to the New York Surgical Society, October 25, 
1886, an incomplete outward dislocation in a child eight years old that 
had existed for only three months, a specimen obtained by excision, the 
capitellum formed an almost hemispherical protuberance upon the front 
and lower part of the epiphysis, the inner side of the trochlea was flat- 
tened, and the external condyle had grown outwardly so far that it pre- 
sented a surface nearly half an inch broad beyond the capitellum ; I 
interpreted the last named change as due to the stripping up of the 
periosteum and the attachment of the external lateral ligament, with the 
consequent formation of new bone on the outer side of the condyle. 

These changes are clearly incompatible with successful reduction by 
the means employed in fresh cases, even if the force employed be suf- 
ficient to rupture the adhesions and bring the bones down to the proper 
level. It is true that successes have been occasionally reported, but the 
reports rarely go beyond the statement that reduction was accomplished, 
and they leave the subsequent history of the case and degree of reestab- 
lishment of the functions unrecorded. Until quite recently the only 
methods employed have been forcible attempts to reduce by traction and 
the breaking of adhesions, sometimes aided by subcutaneous division of 
the tendon of the triceps, or of adhesions on the sides and back of the 
joint, increase of the range of motion by the same means without reduc- 
tion, reduction after fracture of the olecranon by forcible flexion, and 
excision of the joint. 

Albert says that Liston, more than forty years ago, successfully reduced 
an old dislocation after subcutaneous division of all tense bands, and that 
in 1847 Blumhardt successfully practised arthrotomy in a similar case, 
making two lateral incisions, and dividing through them all the adhesions 
that opposed reduction. This case appears to have been entirely lost 
sight of, and it was not until thirty years later, in 1877, that Kiister, 1 in 
reporting a case of fracture and dislocation of the astragalus treated by 
excision, suggested that old dislocations of other joints might be success- 

1 Kiister: Berlin, klin. Wochenschrift, 1877, p. 16. 



TREATMENT OF OLD DISLOCATIONS. 345 

fully treated by arthrotoroy. In the following year Trendelenburg, 1 in 
a paper recommending temporary division of the olecranon to facilitate 
operations upon the elbow-joint, reported a case of incomplete outward, 
or outward and backward, dislocation of both bones with avulsion of the 
epitrochlea which he had treated by making an incision along the tendon 
of the biceps, and chiseling away enough bone from the lower end of the 
humerus in front of. the coronoid process to allow flexion to a right angle ; 
the result was good to that extent. A little later Volker 2 reported a 
case of incomplete outward dislocation of the left elbow of six months' 
standing in a boy thirteen years old, in which, after division of the ole- 
cranon, he had divided the adhesions, dissected away the new tissues in 
the sigmoid fossa, and had then been able to reduce ; as the change in 
the shape of the bones favored recurrence he removed the head of the 
radius. He then sutured the olecranon with two silkworm-gut sutures 
passed from side to side of the bone, closed the wound, and obtained a 
good result. His incision was U-shaped, the sides extending along the 
borders of the triceps, and the bottom of the U crossing the olecranon at 
the point where it was to be divided. The position of the limb (anky- 
losis in almost complete extension) and the evidences of serious pressure 
upon the ulnar nerve were important factors in the determination to 
operate. He was so pleased with the result that he looked forward with 
confidence to the adoption of the method in all old dislocations with much 
disability. 

Trendelenburg 3 promptly claimed priority in the suggestion of prelimi- 
nary division of the olecranon, and reported a case of backward disloca- 
tion of both bones of eight weeks' standing successfully treated in the 
same manner. His incision w r as a curved transverse one, the convexity 
directed upward, crossing the median line well above the olecranon, and 
the flap was then dissected and reflected downward to the point at which 
the olecranon was to be divided ; this division of the olecranon was done 
with a chisel. Because of difficulty in bringing the olecranon down the 
limb was dressed in extension, but after the nineteenth day, wdien the 
wound was healed, the position was gradually changed, and four weeks 
later the joint could be flexed to a right angle. The olecranon reunited 
solidly in this case and in Yolker's. 

In 1885 Nicoladoni 4 published a short paper on the application of 
arthrotomy to old dislocations of various joints, and included in it the 
report of two cases in which he had practised it at the elbow. The first 
case was an almost complete outward dislocation of the left elbow in a 
lad sixteen years old, which had existed for eight months ; the epitrochlea 
was broken off and drawn under the trochlea; the limb was in extension, 
flexion was entirely lost, but rotation was preserved. An incision eight 
centimetres long was made in front along the inner border of the trochlea, 
and through this the fractured epitrochlea was removed ; a second incision 
of the same length was made on the outer side of the joint through which, 

1 Trendelenburg: Archiv fur klin. Chir., 1879, vol. 24, p. 790. 

2 Volker: Deutsche zeitschrift fur Chir., 1880, vol. 12, p. 541. 

3 Trendelenburg : Centralblatt fur Chir., 1880, p. 833. 

4 Nicoladoni: "Wiener med. Wochenschrift, 1885, p. 728. 



846 



DISLOCATIONS OF THE ELBOW. 



after removal of a small piece of bone that had been broken from the con- 
dyles, the soft parts were separated from the radius and the humerus; 
then, through a longitudinal cut made in the tendon of the triceps, the 
adhesions between the olecranon and the back of the humerus were sepa- 
rated, and the bones were then easily restored to place. The wound 
healed after slight suppuration, passive motion was begun after the third 
week, and the patient was dismissed after seven and a half weeks with 
the elbow flexed and movable through an arc of 35° or 40°. Nine 
months later he wrote that he would flex and extend the joint freely, but 
that rotation was not quite so free. 

The second patient was a large, powerful man, forty-one years old, with 
a backward dislocation that had existed for six months. The limb was 
almost completely extended and immovable ; there was some passive rota- 
tion. The olecranon was situated unusually high. Two lateral incisions, 
each sixteen centimetres long, were made ; through the first, over the 
outer condyle in front of the head of the radius, the soft parts were 
separated from the bone, leaving the periosteum undisturbed, into the 
trochlea and above the fossa trochlearis in front and behind ; the separa- 
tion from the cartilage was easy in front, but very difficult behind; 
through the second incision, on the inner side of the elbow, the flexor 
muscles were cut away close in front of the epi trochlea, and the separa- 
tion of the soft parts from the bones completed. The greater sigmoid 
cavity was found filled with hard cicatricial tissue, which was cut and 
scraped away after separation of the posterior attachment of the orbicular 
ligament. Reduction was then easily made, 
the flexor side of the joint, and one through 
the wound was closely sutured, a Lister dressing applied, and the limb 
placed in a splint. Recovery took place without incident, and the patient 
was dismissed at the end of four weeks, the wounds being almost healed. 
There was good active rotation, but very little 
flexion ; passively, there was complete extension 
and flexion to a right angle. 

In a personal case the result of a similar opera- 
tion was not satisfactory, and the subsequent 
operation which became necessary showed nutri- 
tive or inflammatory changes in the bones and 
cartilages, as the apparent result of the first one, 
which might have seriously interfered with the 
usefulness of the joint. The patient was a girl, 
eleven years old, with a backward dislocation of 
both bones, of five months' standing. The limb 
was flexed at an angle of 150°, and was immova- 
ble except for some rotation. The operation was 
done in April, 1886. A free incision was made 
on the outer side, through which a mass of bone 
of new formation (Fig. 92) on the back of the 
external condyle, extending downward to form a 
new socket for the head of the radius, was chiselled away ; the anterior 
part of the capsule was easily separated from the articular cartilage of the 
humerus, which appeared smooth and unaltered, but the dissection behind 



Two drains were placed on 
the tendon of the triceps ; 



Fig. 92. 




New formation of bone in an old 
unreduced dislocation. 



TREATMENT OF OLD DISLOCATIONS. 347 

the humerus was made very difficult by the interposition of a mass of 
cicatricial tissue between it and the greater sigmoid cavity, which entirely 
filled, and was firmly adherent to, the latter. Dr. McBurney, who was 
kindly assisting me, advised the making of a second incision upon the 
inner side of the elbow, but, unfortunately, I preferred to divide the 
olecranon, being encouraged so to do by the reports of some of the above- 
mentioned cases, and by personal experience of the method in operations 
for tubercular disease of the joint. So the incision was extended across 
the olecranon, and this process was divided obliquely at its thinnest 
part. The back of the condyles was then easily freed, and the epi- 
trochlea was found to have been broken off, and to have reunited with 
the humerus at some distance above its normal position. The attached 
internal lateral ligament was then separated from it, and the bones were 
then readily brought into place. The olecranon was sutured with silk- 
worm-gut, the wound closed, with a drainage tube behind the condyle, 
and the limb placed in a splint with the elbow at an angle of about 145°. 
The remaining attachments of the olecranon made further flexion seem 
undesirable. Two days later the dressings were changed, and the limb 
enveloped in plaster-of-Paris bandages. A week later a fenestra was cut 
and the tube withdrawn ; little or no suppuration. During the following 
month I was absent from the city; on my return the dressing was 
removed, and the w x ound found to be healed, but the dislocation had 
recurred. A second operation was done two months after the first, by a 
curved incision, its convexity upward, starting just below the head of the 
radius, and crossing above the olecranon ; the ulnar nerve was exposed 
and drawn aside, and the joint opened by cutting through the triceps. 
The joint surfaces were found almost denuded of cartilage, and much 
changed in shape by bony and fibrous growths at their borders, so I 
excised the lower end of the humerus and the head of the radius ; the 
bone was much softer than usual. I enlarged the sigmoid cavity, and cut 
a notch in the lower edge of the humerus to receive the olecranon ; catgut 
drains. Close fibrous union of the former division of the olecranon was 
found. The wound healed without incident in thirteen days, and the 
patient was subsequently dismissed with flexion to within a right angle 
and almost complete extension. On looking her up eight months later I 
found complete bony ankylosis at a right angle. 

I do not think the division of the olecranon directly favored the recur- 
rence of the dislocation in this case ; it was rather due to the posture of 
only partial flexion in which the limb was placed, but as the choice of 
this posture w T as imposed by the necessity of avoiding a strain upon the 
olecranon that might have prevented its reunion, the division was the 
indirect cause. In another case I should use the method by two lateral 
incisions without division of the olecranon. 

The change in the cartilage could hardly have been caused by the 
inflammatory reaction following the operation, for that was not sensibly 
greater or more prolonged than after the original dislocation. I am 
inclined to attribute it rather to the keeping of the knife too close to the 
bone in the separation and freeing of the soft parts, and think, therefore, 
that in a similar case it would be better to divide the adhesions than to 
dissect them from the humerus. 



348 DISLOCATIONS OF THE ELBOW. 

The reported cases are too few to permit much generalization, but the 
large measure of success which they have furnished is an encouragement 
to further trial. In the meantime, the rules of conduct in the presence 
of old backward dislocations of the elbow formulated by Albert appear to 
be judicious. ' He says that in elderly patients he limits interference to 
rupture or subcutaneous division of the adhesions, and that if reduction 
then fails he forcibly flexes the elbow to a right angle, with or without frac- 
ture of the olecranon, and allows it to become ankylosed in that position. 

In younger patients he makes the attempt to reduce, sometimes dividing 
the tendon of the triceps so as to avoid fracturing the olecranon ; reduc- 
tion failing, he does an arthrotomy with two lateral incisions, and if this 
also fails he proceeds to resection. This advice was formulated before 
the publication of the method by division of the olecranon, but I should 
not change it in favor of resorting to the latter. 

In old incomplete outward lateral dislocations little is to be hoped for 
from forcible subcutaneous rupture of the adhesions, for the common 
interposition of the fractured epitrochlea cannot thus be overcome, and 
the probabilities are decidedly against the success of an attempt to remove 
by this means the cicatricial obstacles on the inner side. The choice 
will probably lie between improving the attitude by forcible flexion, if 
the limb is extended, and arthrotomy, the internal incision being made in 
front of the trochlea rather than upon its side. 

In old dislocations of the radius alone, in which partial or complete 
ankylosis renders an operation desirable, the examples quoted in the pre- 
ceding chapter may serve as guides. In those cases in which the dislo- 
cation has occurred in childhood and has been followed by exaggerated 
growth in length of the radius excision of its head is the only suitable 
operation. The results in the reported cases are not very encouraging. 

Sprengel 1 reports a case of dislocation backward and outward of five 
weeks' standing in a boy six years old in which he effected reduction and 
obtained a perfect functional result by arthrotomy and removal of a por- 
tion of the back of the capsule that was interposed between the head of 
the radius and the ulna. He made an anterior incision along the edge of 
the supinator longus, exposed the musculo-spiral nerve and its two 
branches and drew them outward with the outer flap ; by this means the 
capsule was freely exposed to view, and he was enabled to see that the 
rent was on its outer side, and then by drawing the head of the radius 
outward with a sharp hook the obstacle to reduction was found to be a 
fold of the posterior portion of the capsule (probably part of the annular 
ligament) interposed between the radius and ulna, and firmly adherent 
to the lower sigmoid cavity. After having liberated this fold he was able 
to replace the head of the radius and to close with .catgut sutures the 
rent in the capsule except over a small space on the outer side. 

He refers to a case of backward dislocation of the head of the radius 
in which he obtained a similar success by arthrotomy and separation of 
the capsule from the upper surface of the radius. 

1 Sprengel : Centralblatt fur Chirurgie, 1886, p. 153. 



CONGENITAL AND PATHOLOGICAL DISLOCATIONS. 349 



Congenital and Pathological Dislocations. 

Although a considerable number of cases have been reported as con- 
genital dislocations of the upper end of the radius, yet in all of them 
the proof that the deformity existed at birth is defective ; in a few it was 
noticed at so early a period that the probability of its congenital existence 
is great ; in others, and even in those in which both radii were affected, 
the displacement can be referred with equal plausibility to causes operating 
after birth, and the alterations in the shape of the bones to the effect of 
the displacement and the changed functional conditions. 

To the 13 alleged cases briefly quoted and analyzed by Malgaigne, 9 
of which are quoted in detail by Gurlt, 1 may be added several that have 
been since reported, those of Humphrey, 2 Hayem, 3 Mitscherlich, 4 Allen, 5 
Hamilton, 6 Phillips, 7 Pye-Smith, 8 and Heele. 9 In addition is a case, a 
dislocation forward, observed and briefly mentioned by Kronlein ; it is 
quoted in Chapter XVIII. , under congenital dislocations of the shoulder. 

The first -4 were examined post-mortem, the others only clinically. 
In 4 of them the dislocation was backward, in 3 forward ; in all both 
radii were dislocated. Humphrey's, Hayem's, and Allen's were in adults, 
of whom no previous history was obtained. In Humphrey's the lower 
part of the left ulna was lacking evidently because of defective develop- 
ment ; the right ulna (Fig. P3) was firmly ankylosecl to the humerus 

Fig. 93. 




Dislocation of the head of the radius upward in consequence of arrest of development of the ulna. 

nearly at a right angle, and was eight inches long, its lower end was well 
formed and was on the usual level with the radius ; the radius was also 
eight inches long, and its head was displaced upward and rested against 
"the forepart of the ridge that ascends from the outer condyle to the 
shaft," it was somewhat irregular in shape, and its extra length was 
developed in its shaft and not in its neck as in several of the other 
reported cases. The trochlea of the humerus was imperfect. The dis- 
placement upward was clearly the result of the elongation of the radius, 

1 Gurlt: Beitra<re zur Vergleich. path. Anat. der Gelenkkrankheiten, 1853, p. 317. 

2 Humphrey : Med. Chir. Trans, vol. 45, p. 296. 

3 Hayem : Bull, de la Societe Anatomique, 1864, r>. 56. 

* Mitscherlich : Arch, fiir klin. Chir., 1865, vol. 6, p. 218. 

5 Allen: Glasgow Med. Jourri., 1880, vol. 14, p. 44. 

6 Hamilton: Lo C . cit., p. 888. 

7 Phillips: British Med. Journ., 1883, i. p. 773. 

8 Pye-Smith : Lancet, 1883, ii. p. 993. 

9 Heele: Lancet, 1886, ii. p. 249. 



350 



DISLOCATIONS OF THE ELBOW. 



whatever the cause of the original displacement from contact with the 
capitellum may have been. 

Mitscherlich's patient was a girl six years old who had been born with 
clubfoot ; both elbows were deformed, and this defect was thought also to 
have existed from birth. The head of the radius could be felt in front of 
the outer half of the coronoid process ; extension was perfect, but flexion 
was limited on the right side to an angle of 70° and on the left to one of 

Fig. 94. 





Congenital dislocation of the left elbow. (Mitscheblich.) 



110°, both hands were supinated. The elbows were more cylindrical in 
form than usual ; the wrist and fingers were slightly flexed but could be 
straightened. The child was of stunted development and rather feeble 
intelligence. Excision of the left elbow was done by von Langenbeck 
with the object of increasing its range of motion, and the child died in 
consequence of the operation. The specimen (Fig. 94) showed that the 
trochlear surface of the humerus was 
narrowed in front by extension upon Fig. 96. 
it of the exceptionally large circular f'X&s 
surface for the head of the radius. (^HlR 
The articular surface of the ulna was 
normal, but the radius was not in 
contact with it. 

Allen's specimen (Figs. 95 and 
96) was taken from the body of an 
elderly man without history. Both 
elbows were affected ; flexion was 
normal, extension possible only to a 
right angle ; rotation was entirely lost, 
the limbs being fixed in pronation. Both radii were dis- 
placed backward, but only the left elbow is described in 
detail. The specimen was not presented as an example of 
congenital dislocation, but only to show the changes effected 
in the bones in consequence of unreduced dislocation in 
early life. These changes modified the shape of the lower 
end of the humerus and of the radius. The radius crossed 
the front of the ulna and was united with it by bony union 
for a distance of about three inches at their upper part ; The same - 
below this part the shaft of the radius was much thickened. 
The neck of the radius was one and a half inches long, so that the head 
was carried well upward behind the humerus on the inner side of the 




Allen's case of cognenital 
dislocation of the elbow. 






CONGENITAL AND PATHOLOGICAL DISLOCATIONS. 351 

olecranon, and this overriding was further increased by the abnormal 
growth of the external cond}<le downward and outward, the extent down- 
ward of the growth being estimated at half an inch. The trochlear sur- 
face was deformed, mainly by the loss of much of its inner lip. The 
olecranon fossa was so far filled up that the septum between it and the 
coronoid fossa was one-third of an inch thick. The shaft of the ulna 
was small ; its lower end was normal and preserved the usual relations 
with the radius. The specimen appears closely to resemble those of the 
earlier cases reported by Sandifort, Dubois, and Verneuil, and has as 
much, or as little, reason to be thought congenital as most of the others. 
It is of value in the interpretation of the changes observed in other 
specimens. 

The report of Pye-Smith's case is very brief. The patient was a 
woman ; the head of the left radius was displaced backward. She was one 
of a family of eleven persons, eight of whom showed abnormalities of the 
joints, one brother having a similar dislocation of the right radius. The 
father, and his father, uncle, and cousins had various deformities, club- 
feet, badly developed nails, etc. 

Phillips's patient was a well developed girl, seventeen years old. " The 
head of each radius formed a well-marked prominence behind the external 
condyle of the humerus. The elbow-joint could be fully extended and 
could be flexed to almost the normal degree, but only with the hand in 
the semi-pronated position. This action was produced mainly by the 
supinator muscle; the biceps appeared to be much atrophied. The head 
of the radius could be rotated to a small extent; and the various promi- 
nences of the elbow-joint, as well as the head of the radius itself, were 
fully developed. The mother of the child stated that the deformity was 
noticed almost immediately after the birth of the patient." The delivery 
was natural and easy. 

Heele's patient was a loose-jointed, choreic boy, eight years old, of 
very backward intelligence. The left radius was dislocated by any slight 
motion and was usually out of place ; it was easily reduced by flexion of 
the elbow or by pressure upon the bone in any position of the limb. The 
right radius was partly dislocated and irreducible, only one-fifth of the 
head remaining in contact with the humerus. Both dislocations were 
"backward and upward." Both condyles seemed small. All movements 
were possible, but rotation was weak, especially supination. The dis- 
placements were noticed shortly after birth ; no history of accident. 

In the last three cases the histories place the appearance of the de- 
formity at so early a period that it is not improbable that it existed at 
birth, or, at least, that the structure and form of the joint were such at 
birth that the displacement was inevitable. In none of the older cases is 
a similar history found ; in R. W. Smith's, 1 which is one of those quoted 
by Malgaigne, the deformity had indeed existed from birth, but instead 
of being a dislocation it was an extreme malformation not only of the 
upper end of the radius but also of its lower end and of the ulna and 
carpus. 

The arguments upon which the attribution of a congenital character 

1 K. W. Smith : Fractures and Dislocations, p. 247. 



352 DISLOCATIONS OF THE ELBOW. 

was based in most of the older eases and in those of Humphrey and 
Hayem, and which apply equally well to Alden's, are the existence of 
the deformity on both sides and the changes in the shape of the articular 
ends of the bones ; in Humphrey's and in Deville's there is in addition 
the lack of the lower part of the ulna. 

The bilateral character, even with persistence of the ligaments, is not 
a proof that the displacement is not traumatic, as Bartel's case, quoted 
above under backward dislocations of the radius, shows, for in it both 
radii were gradually dislocated in a weakly lad by long-repeated efforts in 
pushing a cart. 

The irregularities in the bones may, in part at least, be fairly attributed 
to the change in their relations, especially the very notable one of elonga- 
tion of the neck of the radius reported in several cases. This is in keeping 
with similar instances of overgrowth at other points where the normal 
conditions of pressure have been lost, and with the coincident elongation 
downward of the external condyle of the humerus noted in Allen's case and 
in one of R. W. Smith quoted by Gurlt (loc cit., p. 320). It requires 
only that the displacement should occur before the growth of the skeleton 
is complete. 

In short, although the recent clinical cases approach more nearly to 
the character of a demonstration, Malgaigne's conclusion that a congenital 
dislocation, while probable, has not yet been proved to have existed may 
still be repeated. 

The only recorded case of dislocation of both bones of the forearm at 
birth is one reported by Chaussier and quoted by Pingaud. 1 A } r oung 
woman during the ninth month of pregnancy felt her child move so 
vigorously that she almost lost consciousness. The movements were 
repeated three times in the course of ten minutes ; delivery took place 
normally at term. The child was weak and presented a complete dislo- 
cation of the forearm backward. Malgaigne thought it probable that the 
lesion was produced, not by the convulsive action of the muscles, but by 
the striking of the limb against the wall of the uterus. 

A few instances of dislocation due to pathological changes within the 
joint, such as fungous arthritis or relaxation of the ligaments in the 
course of an acute illness, have been reported. 

1 Pingaud: Diet. Encyclopedique des Sc. Med., art. coude, p. 606. 



CHAPTER XXII. 

DISLOCATIONS AT THE WRIST. 

DISLOCATIONS OF THE LOWER RADIO-ULNAE, JOINT; OF THE RADIO-CARPAL 
JOINT ; OF THE CARPAL BONES ; CARPO-METACARPAL DISLOCATIONS. 

A. Dislocations of the Lower Radio-ulnar Joint. 

These dislocations, obscurely mentioned by the earlier writers, were 
first described, according to Malgaigne, in 1771, by Desault, who reported 
five cases and said he had observed a great number of others. He spoke 
of the injury as a dislocation of the radius, but Boyer and Dupuytren 
preferred to call it a dislocation of the ulna, and their choice has been 
generally accepted and followed. Both traumatic and 'pathological forms 
have been described. The reported cases are comparatively few if those 
cases are excluded in which the injury is a complication of a fracture of 
the lower end of the radius, and those injuries observed in young children 
which are generally thought to be a subluxation of the head of the radius, 
but which some consider dislocations of the lower end of the ulna ; few 
surgeons who have reported their experience have seen more than a single 
case. Tillmanns 1 collected 48 cases in addition to one observed by him- 
self, of which the dislocation was forward in 16, backward in 18, and 
inward in 9, and in 5 the direction was not stated ; but in 3 of the first 
group, 8 of the second, all of the third, and 1 of the fourth, there was 
also fracture of the radius, and in 4 others the ulna perforated the skin 
and there is reason to think the radius also was fractured. Excluding 
the cases complicated by fracture, and including only 3 of Desault's 5, 
there remain 12 dislocations forward and 10 backward ; to these may be 
added 2 backward and 3 forward seen or collected by Hamilton, and 3 
forward collected by Poinsot, making a total of these two varieties of 18 
forward and 12 backward. The reported dislocations inward or, more 
strictly speaking, downward and inward, are really dislocations of the 
broken end of the radius and the attached carpus upward ; to these may 
be added also the few cases of dislocation of the head of the radius (q. v.) 
in which the entire bone has been displaced upward along the ulna. 

In the preceding chapter mention has been made of the theory ad- 
vanced by Groyrand, that the injury frequently seen in very young 
children and generally thought to be a subluxation of the head of the 
radius by elongation was a dislocation backward of the lower end of the 
ulna. Although the theory cannot be accepted as a correct explanation 
of the great majority of the cases, yet it may be true of some of them — 
of those few in which pain and swelling are found only at the back of the 
wrist — and if so the list of reported cases of the injury now under con- 

1 Tillmanns: Arch, der Heilkiinde, 1874, vol. xv. p. 249. 
23 



354 DISLOCATIONS AT THE WRIST. 

sideration would have to be increased by additions to the backward 
variety, which would make it the more common of the two. 

Dislocations backward. — The cause in most of the cases tabulated 
above was exaggerated pronation of the wrist ;. in some the mechanism is 
not indicated, and in others it is not clear. A few of them, Desault, 
Duges, Rendu, have been included either by the surgeon himself (Rendu) 
or by other writers among dislocations of the upper end of the radius by 
elongation, and in these the injury was produced in very young children 
by traction upon, or forced pronation of, the hand. As above stated, 
several other cases, notably some of Snedden's (see Chapter XX., p. 000), 
presented similar symptoms and probably belong in this group. Some- 
times the exaggerated pronation has been eifected by external violence, 
as in Boyer's case, in which a lad engaged his hand between the spokes 
of a moving wheel ; sometimes by muscular action, as in one of Desault's, 
a washerwoman who was wringing clothes, or in one of Rognetta's, a 
carpenter who was drilling a hole in a plank ; Dalechamp's patient was 
bitten at the wrist by a horse. 

The pathology has not been shown by direct examination of either 
recent or old cases, and the only experiments bearing upon it are those 
of Goyrand, quoted in Chapter XX., and they show only that by ex- 
aggerated pronation the triangular fibro-cartilage uniting the radius and 
ulna could be carried so far forward as to clear the end of the ulna 
entirely ; he did not succeed in producing by this means a dislocation 
that would maintain itself without the aid of pressure upon the hand. It 
seems probable that in the clinical cases there was also rupture of the 
posterior radio-ulnar ligament. 

Symptoms. — The hand is slightly or markedly pronated; its adduction 
has been noted by some, and diminution of the transverse diameter of the 
wrist by others. Flexion and extension of the wrist are free ; supina- 
tion difficult. 

The deformity consists in a marked projection of the lower end of the 
ulna on the back of the wrist, and a corresponding depression in front ; 
the ulna may, in addition, slightly overlap the end of the radius, so that 
its axis if prolonged downward would pass to the middle finger. 

The diagnosis appears to be easy, the exception being again noted of 
the possible cases occurring in young children, in which the only symp- 
toms are pain and swelling at the back of the wrist. Malgaigne calls 
attention to the danger of mistaking the cause for the effect in old cases 
in which the dislocation follows a chronic arthritis, and also of overlooking 
an associated fracture of the radius. 

Reduction has always been readily effected by direct pressure on the 
radius, aided sometimes by abduction or supination of the hand ; occa- 
sionally supination alone has been sufficient, and this is the rule in the 
supposed cases in young children. Even in old cases — sixty days — 
reduction has been easily made. 

Recurrence has been noted in three cases. In one of Hamilton's the 
dislocation had existed twenty years, but the movements of the limb were 
perfect. 

Dislocations forward. — Dislocation of the lower end of the ulna for- 
ward appears commonly to have been caused by direct violence acting in 



DISLOCATIONS OF LOWER RADIO-ULNAE JOINT 



355 



Fig 



opposite directions upon the lower ends of the radius and ulna while the 
hand was more or less supinated. It does not clearly appear that the 
cause has ever acted by carrying the movement of supination beyond its 
normal limit, although it is not improbable that this was the case in one 
or two instances. 

No post-mortem examination has been reported, and the pathology of 
the injury can, therefore, only be inferred, Desault, however, met with 
a specimen of an old dislocation in the cadaver of a man sixty years old ; 
the hand could not be extended, and rotation was very limited. The 
sigmoid cavity of the radius was filled with cellular tissue ; the head of 
the ulna, situated in front of this cavity, rested on a sesamoid bone to 
which it was attached by a capsular ligament. Other injuries had con- 
tributed to the loss of motion. The hand was (Edematous ; the flexor 
tendons, pushed outward, adhered to one another and to the skin ; the 
elbow could not be extended, and both shoulders were dislocated forward 
(Malgaigne, loc. cit., p. 688). 

In an entirely unique case reported by Valleteau 1 the dislocation was 
compound. The patient's forearm had been caught between the spokes 
of a moving wheel; the ulna pro- 
jected twenty-eight lines through the 
skin, crossing the front of the radius, 
which appears not to have been 
broken. 

Symptoms. — The forearm is partly 
pronated or in varying degrees of 
supination, the wrist flexed or ex- 
tended, rotation difficult and painful. 
The lower end of the ulna is promi- 
nent in front, with a corresponding 
depression behind, and sometimes 
displaced toward the outer side so 
that it overlaps the front of the 
radius and its axis is directed toward 
the middle of the hand. 

The diagnosis is easy, but search 
should be made, as in the preceding 
variety, for the possible coexistence 
of a fracture of the radius. 

The best method of reduction 
appears to be by direct pressure upon 
the ulna and counter-pressure in the 
radius. 

Dislocations inward and down- 
ivard (Fig. 97) have been observed 
only in connection with fracture of 
the radius or, very rarely, with dis- 
location of its upper end, and are to be deemed complications or incidents 
of the other and more important injury. 




Fracture of the radius and ulna ; displacement 
upward of the lower fragment of the radius. 
(Malgaigne.) 



Valleteau : Gazette Medicale, 1836, p. 250. 



356 DISLOCATIONS AT THE WEIST. 

In like manner, the serious complication of perforation of the skin 
by the ulna has occurred only once except in connection with fracture of 
the radius. 

Pathological dislocations have been reported as the consequence of 
chronic suppurative arthritis and also of non-suppurative arthritis pro- 
voked by a sprain or by a fracture of the radius. Possibly the case 
reported by Rognetta 1 of a negro who suffered from an habitual dislocation 
backward gradually produced by the effects of his occupation as a Avood- 
sawyer belongs in this category, the ligaments having become relaxed in 
consequence of an arthritis set up by the constantly repeated mechanical 
violence of the movement. 

B. Dislocations of the Radio-carpal Joint. 

These dislocations, long thought to be common because fracture of the 
lower end of the radius was habitually supposed to be a dislocation until 
Dupuytren forced a recognition of the error, are now known to be of. 
infrequent occurrence. Dupuytren, in the vigor of his correction of the 
error, went to the other extreme and pronounced them unknown or of 
very great rarity, and this assertion has colored the general opinion 
concerning their frequency even to the present time. The statistics that 
have since been collected are not entirely trustworthy, perhaps, for the 
error in diagnosis appears still to be made and all reported cases cannot 
be unhesitatingly accepted, but there is reason to think that the rarity 
is not very great, and there are enough well-authenticated cases to make 
it possible to trace a general description of the injury. Malgaigne col- 
lected 14 cases, 8 of backward, 6 of forward dislocation. Parker 2 
collected 33 cases, 23 backward and 10 forward. Tillmanns (loc. cit.), 
1874, collected 24, 13 backward and 10 forward ; and Servier 3 in 1880 
collected 26 besides 1 observed by himself, 13 backward, 13 forward, and 
1 outward, of which about 19 were not contained in Tillmanns's paper. 
I have found 13 cases published since 1880 and have myself observed 1, 
12 backward and 2 forward, and it is worthy of note that 5 of these were 
reported in the British Medical Journal within six weeks of one 
another, March and April, 1880, the reports of the last 4 having been 
called out by that of the first. In addition, Albert speaks of 5 within 
his knowledge or observation. Even supposing Parker's 33 to include 
all of Malgaigne's and Tillmanns's, and counting 19 of Sender's, this 
would still give a total of about 70 cases more or less well authenticated, 
the correctness of the diagnosis in a number of them being entirely 
beyond question. 

The necessity of receiving with some caution those cases that have 
been observed clinically and reported with scanty detail is shown by the 
errors in diagnosis that have been made by experienced surgeons fully 
aware of the difficulty. Malgaigne (loc. cit., p. 703) narrates three 
striking cases. At the time when Dupuytren was first questioning the 

1 Kognetta: Archives gen. de Med. 1834, vol. 5, p. 396. 

2 Parker: Trans. South Carolina Med. Assoc. Abstract in N. Y. Med. Record, 
1871, vol 6, p. 396. 

3 Servier: Gazette Hebdom., 1880, p. 211. 



DISLOCATIONS OF RADIO-CARPAL JOINT. 357 

correctness of the diagnosis in which fracture of the lower end of the 
radius was habitually taken to be a backward dislocation of the wrist, a 
patient presenting all the usual signs of this injury died at the Hotel 
Dieu. Pelletan declared it to be a dislocation, Dupuytren a fracture, 
and the former did not vary from his opinion until after the last stroke 
of the scalpel had exposed the bone and showed the injury to be a frac- 
ture with crushing of the lower end of the radius. In 1834: Roux made 
the diagnosis of dislocation backward in the case of a child that had 
fallen from a tree ; again dissection proved it to be a fracture, with 
separation of the epiphysis. Still more remarkable was a case reported 
by Chassaignac 1 in which he excised the projecting ends of the radius 
and ulna, thinking the case was dislocation ; on careful examination it 
proved to be a separation of the epiphysis of the radius. The difficulty 
is probably not so great in dislocations of the carpus forward. 

The dislocation may be complete or incomplete backward or forward, 
and in one case was incomplete outward ; it may be simple or compound, 
or associated with fracture of the radius or ulna. Apparently fracture 
of the edge of the articular surface of the radius on the side toward 
which the carpus is dislocated is not infrequent; such fracture of the 
posterior lip of the radius is known in this country as " Barton's frac- 
ture," but it appears to me properly to belong among the dislocations, 
the fracture being only an incident or complication. The incomplete 
dislocations are mainly those in which only the outer portion of the 
carpus, the scaphoid and semilunaris, are dislocated from the radius, 
while the inner portion maintains its relations with the triangular fibro- 
cartilage and ulna ; this variety appears to be produced by a movement 
of rotation (pronation or supination) in which either the radius or the 
carpus is kept stationary while the other moves away from it ; it appears 
to be sometimes associated with disturbance of the relations of the lower 
radio-ulnar joint. 

In addition to the traumatic, a few pathological and congenital dislo- 
cations have been reported. 

Dislocations backward. — The causes of this dislocation are character- 
ized by great violence, as a fall from a height upon the palm of the hand ; 
in some cases the wrist appears to have been flexed forward, " doubled 
under'' the patient, in a fall while walking, or from a slight elevation : 
and in one case, Chapplain, 2 the injury appears to have been caused by 
direct violence, the wrist having been caught between the buffers of two 
railway cars. In the first form it appears probable that the anterior 
ligament yields, and that then the carpus slips backward upon the radius 
and ulna ; in the second, the posterior ligament must be the first to 
rupture. 

In two almost identical cases, Billroth, 3 Rydygier, 4 the mode of pro- 
duction is clearly shown : in the former, the patient, while pressing with 
the palm of his hand against a railway car in an effort to arrest its 
motion, was struck upon the back of the elbow by another car moving in 

1 Chassaignac : Bull, de la Societe de Chir., 1868, p. 225. 

2 Chapplain : Bull, de la Soc. de Chirur., 1874, vol. 3, p. 461. 

3 Billroth : Arch, fur klin. Chir., vol. 10, p. 601, quoted by Tillmanns. 

4 Rydygier: Deutsche Zeitschrift fur Chirur., 1881, vol. 15, p. 289. 



358 DISLOCATIONS AT THE WRIST. 

the opposite direction, and a compound dislocation of the wrist was pro- 
duced, the articular surfaces of the radius and ulna projecting through 
the skin on the palmar surface, llydygier's patient was caught in the 
same way between a wagon and a wall, alongside of which it was moving. 

The pathology 'is illustrated by a number of post-mortem examinations, 
and by some cases complicated by wounds which permitted direct exami- 
nation of the joint. The autopsy that has been reported with most detail 
is that of a case observed by Voillemier. 1 The patient was a man twenty- 
seven years old, who had fallen from the third story of a building, and 
received injuries which caused his death in four hours. The violence 
that caused the dislocation of the wrist was apparently received upon the 
palm of the hand while in dorsal flexion. The external and posterior 
ligaments were ruptured, the anterior was torn away from the radius, and 
the internal was intact but was separated from the ulna by avulsion of 
its styloid process. The tendons and muscles of the back of the forearm 
were not torn, but had been stripped off the radius, bringing with them 
the periosteum and small pieces of attached bone. The superficial flexor 
muscle was widely perforated and torn by the styloid process of the 
radius at its inner portion, that corresponding to the tendons of the ring 
and little fingers, the remainder being pushed to the outer side together 
with the median nerve and radial vessels. 

In Servier's case, a man twenty-five years old, the ligaments were 
extensively torn, except those portions which bind the semilunar to the 
radius ; all the ligaments that attach the semilunar to the scaphoid, os 
magnum, and cuneiform were torn, and the latter bone was in addition 
almost completely separated from the unciform and was fifteen milli- 
metres distant from the styloid process of the ulna. The carpus, with 
the exception of the semilunar which remained solidly attached to the 
radius, was displaced backward about one centimetre ; the radio-ulnar 
ligament was intact, and there was no fracture of any of the bones. The 
injury was caused by a fall from a great height in which the skull also 
was broken, the patient dying a few hours later. 

Paret's 2 patient was a sailor who had received his injury in a fall from 
a yard to the deck ; the entire anterior lip of the radius projected through 
the skin ; the tendon of the flexor longus pollicis was torn, and the ulna 
broken in its lower third. 

In a case reported by Colgate 3 there was a transverse wound of the 
skin on the front of the wrist, which apparently was not deep and did 
not communicate with the joint. 

In a case reported by Marjolin (quoted by Servier), in which the dislo- 
cation was made compound by a wound at the level of the lower end of 
the radius and the patient died of purulent infection, the anterior and 
external ligaments were torn ; the bones were intact. 

In an old case dissected by Padieu (quoted by Servier) the first row 
of the carpus rested on the back of the radius. 

In Lenoir's case a narrow fragment of the posterior articular border 

1 Voillemier: Arch. gen. de Med., 1839, vol. (5, p. 401. 

2 Paret : quoted by Servier and Tillmanns. 
8 Colgate: Lancet, 1873, I., p. G97. 



DISLOCATIONS OF RADIO- CARP AL JOINT. 359 

of the radius had been broken off ; it remained attached to the capsule 
and was displaced backward with the carpus. This is the so-called 
" Barton's fracture of the radius '' (see Fractures, p. 453). In no other 
autopsy of a backward dislocation has this fracture been reported, but it 
has been suspected to exist in some of the cases observed clinically, and 
a few specimens of the reunited fracture without history are in existence. 

In a case quoted in the Centralblatt fur Chirurgie, 1884, page 279, 
both styloid processes were broken. 

Of the incomplete form, that in which only the outer portion of the 
carpus is dislocated, the only case given in sufficient detail is that of 
Dupuy i 1 the patient, a young and muscular porter, while trying to lift 
a cask had his hand forcibly supinated while the radius remained pro- 
nated. On examination two hours later the hand was found flexed and 
half supinated, while the radius was pronated. Both styloid processes 
could be distinctly felt, that of the ulna in its normal relations with the 
carpus, but that of the radius and the articular surface of the latter pro- 
jecting as a ridge on the posterior aspect of the wrist. Fifteen 
millimetres above the posterior margin of the end of the radius was a 
rounded bony prominence, highest on the outer side and gradually 
diminishing toward the ulna. No crepitation ; no shortening of the 
limb. Reduction was effected by traction and direct pressure. 

In short, the dislocation is habitually accompanied by an extensive 
laceration of the ligaments, especially the anterior and external ; avul- 
sion of the posterior lip of the articular surface of the radius may take 
the place of rupture of the posterior ligament. The extensor tendons 
are lifted from their grooves but not torn ; the flexors may be torn or 
pushed to the outer side by the projecting radius ; the median nerve and 
radial artery have always escaped injury, even when the radius has been 
driven through the skin. The carpus may be displaced directly back- 
ward so as to rest upon the posterior surface of the radius, without 

Fig. 98. 




1 

Dislocation of the carpus backward. (Fergusson.) 

change in the relations of the several bones that constitute it, or with 
more or less separation of them from one another, the semilunar bone in 

1 Dupuy : Journ.de Bordeaux, July, 1850, quoted by Tillmanns. 



360 DISLOCATIONS AT THE WRIST. 

one case being completely detached from the others and remaining 
attached to the radius ; or the displacement may be complete only on the 
radial side, the movement being one of rotation (supination) of the carpus 
turning on its inner side as a centre. Fig. 98, from Fergusson, repre- 
sents the position of the bones in the complete form. A superficial 
transverse rent in the skin on the palmar surface of the wrist observed 
in one case was probably caused by overstretching of the skin across the 
projecting end of the radius. 

Symptoms. — The deformity bears a close resemblance to that of 
Colles's fracture, but yet the differences are such that Albert (Chirurg., 
vol. 2, p. 440) says he was able to make the differential diagnosis at sight. 
These differences are that the swelling on the anterior aspect of the wrist 
and lower part of the forearm extends further down, nearer to the hand, 
in dislocation than in fracture, reaching even to the ball of the thumb, 
and ends more abruptly ; that on the back of the wrist is more sharply 
outlined at its upper border (Fig. 99). In addition, the hand and wrist 
are commonly more flexed upon the forearm and less movable in dislo- 
cation, and may be adducted. 

On palpation the styloid processes should be recognized, and their 
relations to each other and to the bones of the hand and wrist deter- 
mined ; in fracture the styloid process of the radius is displaced upward 

Ftg 99 





Diagrammatic, to indicate the deformity in (A) dislocation of the wrist backward, 
and (B) Colles's fracture of the radii 






to or above the level of that of the ulna, its distance from the head of the 
second metacarpal bone, for instance, is unaltered, and its distance from 
the external epicondyle of the humerus is lessened ; while in dislocation 
the styloid process of the radius remains on a lower level than that of 
the ulna, its distance from the head of the second metacarpal bone is 
lessened, and that from the external epicondyle unaltered ; it is also 
further removed anteriorly from the back of the wrist, and may perhaps 
be felt projecting under the skin on the inner side of the radial artery 
and some of the flexor tendons. 

In some of the cases the upper margin of the dorsal swelling could be 
distinctly felt to be hard and rounded, the convexity directed upward, 
and the bony thickness of the wrist to be notably increased antero- 
posteriorly, and movable upon the shaft of the radius. The anterior 
swelling is hard and irregular. 

Reduction has usually been easily effected by traction upon the hand, 
and direct pressure on the carpus, and as a tendency to recurrence is not 
to be anticipated, no other dressings are needed than such as will secure 
immobility until the arthritis shall have subsided. 



DISLOCATIONS OF RADIO-CARPAL JOINT. ' 361 

In compound cases the treatment should be rigorously antiseptic, with 
ample provisions for drainage. Many surgeons think that a partial 
excision in such cases favors recovery without accident, but I believe that 
opinion to be a survival from the pre-Listerian days, and that cleanliness, 
drainage, and rest will make excision unnecessary. 

The prognosis is favorable in the uncomplicated cases, and even when 
the dislocation has remained unreduced the reestablishment of the func- 
tions of the joint has been satisfactory. 

Dislocations forward. — The causes of the forward dislocations have 
commonly been a forcible bending of the hand forward or backward. In 
two cases it was direct violence ; in "one of them, Moore, 1 the fall of a heavy 
weight upon the wrist while the latter was resting on the , ground (the 
account does not state whether the forearm was resting on its anterior or 
posterior surface) ; in the other, Dieu, 2 the patient was kicked on the 
back of the hand by a horse. 

Pathology. — Six autopsies have been reported, Malle, 3 Letenneur, 4 
Collin, 5 Jarjavay, 6 Boinet, 7 and Groodall. 8 In addition, there is a compound 
dislocation, for which Bransby Cooper 9 amputated ; the position and 
extent of the wound are not stated, the only detail that is given being 
that "the flexor tendon of the thumb was torn through." These autopsies 
show rupture of the anterior and external lateral ligaments, and some- 
times of all, the carpus being displaced well upward along the anterior 
aspect of the radius and ulna ; in one case, Goodall, the connection 
between the semilunar and cuneiform was destroyed, the latter bone 
retaining its normal relations with the triangular fibro-cartilage, while the 
scaphoid and semilunar with the rest of the carpus were displaced forward 
and upward, so that these two bones passed over the free torn border of 
the ligament stretching from the styloid process of the radius to the cunei- 
form, which was thus left interposed between them and the articular 
surface of the radius, and prevented complete reduction. Apparent 
reduction was easily effected during life, but the displacement at once 
recurred ; there were other wounds, and the patient died of tetanus on 
the eighth day. The anterior lip of the articular surface was broken off 
in two cases, and in one of these and another the styloid process of the 
radius was broken off. Fracture of the styloid process was observed 
clinically by Malgaigne, and fracture of the anterior lip was suspected 
in a case treated by me in 1882, because of crepitation perceived during 
reduction, and because of the facility with which the dislocation could be 
reduced and reproduced. Boinet says that in producing the dislocation 
upon the cadaver he always fractured the anterior lip of the radius. 

Symptoms. — The hand may occupy any position between moderate 
dorsal and palmar flexion, the latter being the more common, and the 

1 Moore: N. Y. Med. Kecord, 1880, vol. 18, p. 96. 

2 Dieu: Bull, de la Societe de Chirurgie, 1884, p. 296. 

3 Malle: quoted by Malgaigne, Tillmanns, and Servier. 

i Letenneur: Bull, de la Societe Anatomique, 1839, vol. 14, p. 162. 

5 Collin: Ibid., 1844, p. 335. 6 Jarjavay: Ibid., 1861, p. 312. 

7 Boinet: Bull, de la Societe de Chirurgie, 1868, p. 211. This specimen was taken 
from the body of an old woman in the dissecting room ; possibly the case was one of 
" spontaneous " dislocation. 

8 Goodall: Lancet, 1878, i. p. 937. 9 Cooper: Loc. cit., p. 422. 



362 DISLOCATIONS AT THE WRIST. 

fingers are slightly flexed. Voluntary and passive movements of the 
wrist are restricted and painful. In a case reported by Roland, 1 a boy 
twelve years old, who had fallen five or six feet and struck upon the back 
of his flexed right hand, the wrist was immovable in right-angled flexion, 
and the fingers were flexed into the palm and could not be straightened. 
During the struggles of etherization the bones' snapped back into place; 
there was no tendency to recurrence, and the boy made a prompt recovery, 
using the hand freely in a few days. The deformity consists in a marked 
depression on the back of the wrist, the upper border of which is marked 
by the sharply projecting outline of the radius and the end of the ulna, 
and in a corresponding rounded prominence on the front of the wrist, 
formed by the displaced carpus. The hand appears to be shortened at 
the expense of the wrist, and an actual shortening can be demonstrated 
by measurement from the styloid process of the radius to the finger. The 
antero-posterior diameter of the wrist is increased. 

In the old cases (Collin, Jarjavay, Boinet) a new articular surface had 
formed on the anterior surface of the radius and ulna, in two of the cases 
a full inch above their lower ends. In Collin's the limb was equal in 
strength and freedom of use to the other, and all the movements were 
complete except those of abduction and adduction of the wrist, in which 
there was slight and greater loss respectively. 

Reduction has been easily effected, with or without anaesthesia, by 
traction upon the hand or by direct pressure on the displaced bones, or 
by a combination of the two. In my case slight displacement forward 
persisted. 

Dislocations outward. 

Of this form of dislocation only one case has been reported, by Chap- 
plain, 2 of Marseilles. The patient Avas a man, forty-seven years old, 
who had fallen from a height of four metres, the weight of his body 
being received upon his left hand. The hand was widely displaced to 
the outer side, and through a wound situated upon the inner side of the 
wrist the bones of the forearm projected and exposed their entire 
articular surface. The wound of the skin extended from the junction 
of the posterior and internal surfaces of the wrist, around the latter, and 
half-way across the anterior surface. The styloid process of the radius 
had been broken off, and it accompanied the carpus in its displacement. 
The pisiform was almost completely detached and crushed ; the connec- 
tions of the semilunar with the carpal bones had been ruptured, and it 
preserved its relations with the radius. There was no bleeding. There 
was, in addition, a dislocation of the elbow backward. 

The fragments of the pisiform, the styloid process of the radius, and 
the semilunar were removed, and the dislocation easily reduced. A 
single suture was placed at the centre of the wound, and the hand and 
forearm were thickly enveloped in cotton firmly bound on (Guerin's 
dressing). A second dressing was applied on the eleventh day and 
removed on the twenty-second, when a large abscess was found on the 

1 Roland : Phila. Med. Times, 1879, vol. 9, p. 430. 

2 Chapplain : Bull, de la Societe de Chirurgie, 1874, p. 479. 



DISLOCATIONS OF RADIO-CARPAL JOINT. 363 

back of the hand and forearm, and the wound made at the time of the 
accident nearly healed. The abscess was opened at three points, and, 
at the time of the report, the seventieth day, was still discharging, but 
the quantity of pus was growing less, and the wounds were closing. A 
subsequent note, five and a half months after the injury was received, 
states that the wounds were all healed, the phalangeal and metacarpo- 
phalangeal joints had almost entirely regained their mobility, the wrist 
was completely ankylosed, and the elbow only slightly movable. 

Pathological Dislocations of the Radio-carpal Joint. 

These dislocations, so far as they are due to destructive disease of the 
joint, are of secondary interest, and do not readily lend themselves to a 
general description. Malgaigne quotes a few cases, generally reported 
briefly, of dislocations forward that had been slowly produced in conse- 
quence of hydrarthrosis, arthritis, permanent contraction of the flexor 
muscles, and the retraction of cicatricial bands ; he refers also to two 
cases briefly mentioned by Guerin among his congenital dislocations, 
one in a child of six years, and the other in a girl of fourteen years with 
incomplete paralysis of the muscles of the forearm, in which the disloca- 
tion was backward and upward and backward and outward respectively. 
A more common form, one that has been seen with sufficient frequency 
to have received special study, is the following : 

Spontaneous subluxation fortvard. 

This affection was first described by Dupuytren 1 as a condition of the 
joint which might be mistaken for a dislocation, and of which he had seen 
a considerable number of cases, especially in men whose occupations com- 
pelled them to make repeated, sudden, and violent traction with their 
hands, as in working a press or dressing cloth. He said that under 
the influence of these efforts the ligaments of the joint became stretched 
so that the bones Avere capable of more extensive change of place than 
was normal ; the carpus, being no longer held firmly against the bones 
of the forearm, yielded to the traction of the flexor muscles and shifted 
to a position in front of their lower ends. All the signs of a dislocation 
were present except pain and inflammation. The more or less consider- 
able deformity and weakness were the only inconveniences of the con- 
dition, and were not sufficient to cause the patients to intermit their work 
or seek medical help. Ordinarily the deformity could be reduced by 
traction, but it recurred as soon as the parts were left at rest. 

Malgaigne, referring to this description, says that he had for twenty 
years vainly sought an example of the condition in the largest press- 
rooms of Paris, and had met with only one, in a patient thirty-six 
years old, in whom the condition developed at about the age of twelve 
years apparently as the result of carrying heavy burdens ; in this case 
the carpus was displaced forward and upward, three centimetres above 
the lower end of the ulna, and one centimetre above that of the radius, 

1 Dupuytren: Clinique Chirurgicale, vol. 4, p. 209. 



361 



DISLOCATIONS AT THE WRIST. 



the anteroposterior diameter of the wrist was five and a half centimetres 
on the ulnar side, but could be reduced to four and a half centimetres by 
pressure, on the radial side it was only four centimetres, but the articular 
edge of the radius [anterior ?] was much depressed and apparently 
inclined forward. Above the carpus, on the anterior surface of the 
radius, and apparently adherent to it, was a bony prominence. All 
movements were free, except dorsal flexion, which was notably dimin- 
ished. 

In 1878 Madelung 1 read before the Seventh Congress of German 
Surgeons a paper upon the subject based upon the observation of twelve 
cases, and the post-mortem examination of one. Of his twelve patients 
the dislocation was unilateral in ten (four on the right side, five on the 
left, and in one the side was not noted), and bilateral in two ; eight patients 
were females, four males. The earliest age at which the condition origin- 
ated was the thirteenth year ; in only two cases did it begin after the 
twenty-third year. All but one of the patients belonged to the working 
class, but their occupations were not marked by great muscular efforts. 
The specimen was obtained from the body of a woman about twenty 
years old, who had died apparently a short time after confinement. The 
appearance of the limb was so typical that he was convinced of the cor- 
rectness of the diagnosis of spontaneous subluxation, even in the absence 
of any history of the case. There was no sign of chronic inflammation 
of the bones of the arm or of any part of the skeleton. The limb was 
frozen and then sawn longitudinally in two places. The first section was 
(Fig. 100) made through the centre of the os magnum and its articulation 
with the semilunar, and divided the end of the radius so near its ulnar 



Fig. 100. 



Fig. 101. 




Madelung's case of spontaneous dislocation of 
the carpus forward ; longitudinal section through 
(C) the os magnum and (L) the semilunar. 



The same ; longitudinal section through the 
ulna, (ff) the unciform, and (T) the cuneiform. 



border that a portion of the incisura semilunaris shows in the section. 
The second section (Fig. 101) divides the lower part of the ulna into two 
equal parts and passes through the cuneiform, pisiform, and unciform 
bones. The sections show that the radial side of the carpus is displaced 
about half an inch forward and an equal distance upward by the absorp- 
tion of the anterior half of the lower end of the radius, the posterior half 
persisting like a malleolus extended over the dorsum of the wrist, and 



1 Madelung : Deutsche Ge^ell^chaft far Chirurgie, 1878, p. 259, and Archiv fur 
klinische Chirurgie, 1879, vol. 23, p. 395. 



DISLOCATIONS OF RADIO-CARPAL JOINT. 865 

the displacement forward of the ulnar side of the carpus is much more 
marked. 

It seems probable that a case reported by Jean 1 as a double congenital 
dislocation forward w T as of this character. On the right side the cunei- 
form was placed well in front of the ulna ; the semilunar and scaphoid 
not so far in front of the radius, which had formed a new articular 
surface by loss of its anterior lip. In the "left wrist the displacement 
was of the same* character but less marked. Possibly also, Boinet's 
case, quoted above, page 361, and R. W. Smith's case (loc. cit., p. 251) 
of supposed congenital dislocation belong in this class, and also one 
observed clinically and reported by Pooley 2 as a double congenital 
dislocation forward. 

The production of the deformity in the cases observed clinically was 
always gradual, requiring from six months to two years for its full 
development, and in no case could it be attributed to a traumatism, 
either slight or severe, and in no case were there any signs of acute or 
chronic inflammation of any part of the joint. In most cases the 
patients attributed it to continuous hard labor with the hands, but it 
did not appear that this labor was more than usually prolonged or hard. 
The women usually attributed it to washing clothes ; two of the men 
were farmers, one a tanner, and one a shoemaker. In the discussion 
that followed the reading of the paper Hirschberg said he had seen 
two clearly marked cases, the result of practice at the piano. The 
deformity in all the cases was accompanied by pain in the joint and was 
marked especially by the increasing prominence of the end of the ulna. 
After a time the pain ceased, the deformity remained stationary, and 
the freedom of use of the limb was unimpaired except by diminution or 
total loss of dorsal flexion. 

After Madelung's attention had been called to the subject by observa- 
tion of his earlier cases, he took pains critically to examine the wrists 
of people in all . classes of society, and was astonished to find how fre- 
quently he encountered slight deviations from the normal shape, all of 
which were of the type of spontaneous dislocation forward and were 
characterized not only by the abnormal projection of the end of the ulna 
but also by change in the articular surface of the radius and the position 
of the carpus. He attributed the more notable changes in the end of 
radius found in the fully developed cases to the arrest of the growth 
of its anterior portion and to the overgrowth of its posterior portion 
stimulated by the loss of the opposing pressure normally exerted by the 
carpus, and he sees an analogy between this change and those observed 
in pes valgus and genu valgum. 

Symptoms. — The most marked deformity is seen when the limb is 
viewed in profile from the ulnar side; the end of the ulna projects 
markedly at the back of the wrist under the normal, but somewhat 
tense, skin ; the hand is displaced toward the palmar side, and the 
antero-posterior diameter of the wrist is greatly increased. Seen from 
the radial side the displacement forward does not appear so great, and 

1 Jean : Bull, de 1m Societe Anatomique, 1875, p. 398. 

2 Pooley: American Practitioner, 1880, vol. 21, p. 216. 



366 DISLOCATIONS AT THE WRIST. 

the depression below the end of the radius is bridged over by the extensor 
tendons ; if these tendons are relaxed by dorsal flexion of the hand the 
posterior part of the articular surface of the radius can be traced with 
the finger, and its edge can be felt to be rounder than usual. In addi- 
tion, the entire epiphysis appears to be bent forward. 

By traction and pressure the carpus can be brought nearer to the 
ulna, but it returns at once to its former place when the pressure is 
removed. No change can be effected in the relations of the carpus and 
radius. 

Sometimes the region is very painful ; points that are tender on 
pressure are seldom found, and usually only at the upper margin of the 
joint. Every movement of the joint, especially dorsal flexion, is very 
painful. 

Active and passive dorsal flexion is limited to an extent that corre- 
sponds to the degree of the subluxation, and in the most marked cases 
the hand cannot be carried backward beyond straight extension. The 
range of palmar flexion is more often increased than diminished, unless 
pain is present. 

Treatment. — The alteration in the shape of the bones fully explains 
the failure of the few attempts that have been made forcibly to reduce 
the displacement, and the fact that the limb recovers nearly its full use- 
fulness after the growth of the skeleton ceases and the progress of the 
displacement is arrested, furnishes a sound reason against operative inter- 
ference. Prolonged attempts made by Madelung to improve the position 
by fixation in gypsum dressings and methodical manipulations did no 
good beyond relief of pain, and after he had learned the pathology and 
nature of the affection he limited his treatment to efforts to increase the 
strength of the arm in all its parts by methodical use and, in some cases, 
to the wearing of a moulded leather bracelet which could be tightened or 
loosened and was kept in place by a loop passing between the thumb and 
index finger ; this prevented movements of the wrist and left the fingers 
free. 

Congenital dislocations of the radio-carpal joint 

The question of congenital dislocation of the wrist is extremely difficult 
and obscure, for in the great majority of the reported cases the history 
is so defective that the period at which the displacement took place must 
remain uncertain, although in most of them it was certainly during infancy 
or early childhood. In some the congenital origin of the malformation 
can hardly be called in question, because it is marked by great irregu- 
larities of shape and development extending over several bones and joints, 
but the propriety of classifying such cases as dislocations may well be 
questioned, for not only do the joint surfaces present hardly a trace of 
their normal form, but also one or more of the constituent bones may 
be entirely lacking. Such cases seem much more properly to belong 
among the "congenital malformations" and to require classification as 
" club-hands" rather than as dislocations. In most of the reported cases 
in which the deformity has involved only the wrist the theory of congenital 
origin has been based upon the absence of the history of any traumatism 
that could account for the deformity, upon the statements of the patient 



DISLOCATIONS OF THE CARPAL BONES. 367 

or his friends that it had existed as long as they could remember, and 
upon its symmetrical occurrence in both wrists. The history of spon- 
taneous dislocations forward shows how defective this argument is. 

The only alleged example of congenital dislocation which is accepted 
as such by Bouvier 1 and Malgaigne is one reported by Marigues in 1755 ; 
it was observed in a stillborn child. The radius was widely separated 
from the ulna at its lower end, and in the interval between them were 
lodged the bones of the first row of the carpus which were held in place 
by strong ligaments. The ulna was displaced toward the outer side of 
the forearm, the articular surface of the radius was parallel to the first 
row of the carpus, the hand w~as hooked inward, and it was held in this 
position especially by a strong ligament which extended from the second 
row of the carpus to the end of the radius. 

R. W. Smith 2 describes in detail several specimens of displacement 
and deformity which he deemed of congenital origin, and quotes a well- 
known case reported by Cruveilhier in the ninth livraison of his 
Anatomie Pathologique. One of these cases and two or three others 
which have also been reported as congenital have been mentioned in the 
preceding section. It may be added that J. Guerin 3 has described three 
varieties of congenital dislocation — forward, backward and upward, and 
backward and outward — and a fourth class of pseudoluxations to one 
side. Subsequent writers have generally thought his demonstrations 
insufficient or his interpretation incorrect. 

C. Dislocations of the Carpal Bones. 

These present themselves as isolated dislocations of the individual bones 
or as partial or incomplete dislocations of the medio-carpal joint. 

Of the eight bones which form the carpus only the pisiform on the 
ulnar side and the trapezium on the radial side can be distinctly palpated. 
The former is felt as a small, 

hard lump at the junction of Fig. l02 - 

the palm and wrist close below 
the inner end of the lowest of 
the transverse creases that cross 
the wrist ; it rests upon the an- 
terior face of the cuneiform 
bone. The trapezium can be 
readily grasped between the 
thumb and finger just above 
the base of the first metacarpal 
bone. A line drawn straight 

acrOSS the back 01 the WriSt Bones of the wist ; posterior aspect. (Tili.atjx.) 

from one end to the other of 

the lowest transverse crease on the palmar surface crosses the neck of 
the os magnum directly above the base of the third metacarpal when the 
hand is extended in line with the forearm, and the finger can feel a dis- 

1 Bouvier: Diet. Encyclopedique des Sc. Med., art. Main Bote, p. 166. 

2 R. W.Smith : Fracts. and Disloc, 1847, p. 238. 

3 Guerin : Gazette Medicale, 1841, p. 101. 




368 DISLOCATIONS AT THE WRIST. 

tinct depression at this point, the upper margin of which is formed by 
the lower face of the semilunar ; if now the wrist is flexed forward the 
hollow becomes filled by a projecting piece of bone, the head of the os 
magnum. The medio-carpal joint is that between the three bones of the 
first row above and the four bones of the second row below. 

Medio-carpal dislocations. Of these, one dislocation backward, veri- 
fied by autopsy, and two forward, observed clinically, have been reported. 
Possibly some of the cases reported as dislocations of the os magnum 
w T ere of this kind. 

A backward dislocation was reported by Maisonneuve 1 in a patient 
who had fallen from a height of forty feet. The hand, displaced bodily 
to a plane posterior to that of the forearm, was shortened several lines ; 
behind, a few lines below the styloid processes, was a transverse bony 
prominence more than a centimetre high, with a depression below, oppo- 
site the transverse fold of the wrist. The fingers were flexed, and a 
considerable effort was required to extend them. The dislocation was 
not reduced during life, the patient dying soon after his admission to the 
hospital, but after death it could be reduced by slight traction. The 
bones of the second row were completely separated from those of the 
first, and overrode them posteriorly more than a centimetre. A small 
piece of the scaphoid remained attached to the trapezium, and a portion 
of the cuneiform, with the pisiform, accompanied the unciform. The 
internal and external lateral ligaments of the radio-carpal joint were 
completely ruptured, as were also the anterior and posterior ligaments 
uniting the two rows of the carpus. 

An incomplete dislocation forward was reported by Despres. 2 The 
patient was presented with his deformity to the Societe de Chirurgie, 
and as there was a difference of opinion concerning the nature of the 
lesion a committee was appointed to examine and report upon it ; they 
unanimously confirmed the diagnosis. The patient was a man twenty 
years old; the injury was caused by a fall from a swing, probably upon 
the back, the hand being caught between the body and the ground. 
When he came to the hospital, a week later, there was no swelling or 
redness of the region ; on the back of the wrist, a fingerbreadth below 
the edge of the radius, was a depression below which the wrist and hand 
had their normal appearance, and above which, between it and the radius, 
the finger recognized a distinct bony resistance. The axis of the hand 
was deviated outward. On the palmar surface the tendon of the 
pal maris longus and the thenar and hypothenar eminences were promi- 
nent. All the movements of the wrist were preserved, and only forced 
flexion was painful. Forced extension increased the displacement without 
notably changing the form of the palmar surface of the wrist. During 
flexion the prominence of the head of the os magnum was less apparent 
than in the other wrist ; the movement reduced the dislocation. 

The treatment consisted in maintaining the hand in the flexed position 
in which the bone returned to its place by means of a spica bandage ; it 
was begun eleven days after the accident, and by the fourth day the pain 

1 Maisonneuve : Mem. de la Soc. de Chir., quoted by Malgaigne. 

2 Despres : Bull, de la Soc. de Chirurgie, 1875, vol. i. p. 412. 



DISLOCATIONS OF THE CARPAL BONES. 369 

had disappeared and the wrist had regained its form and functions. The 
bandage was worn a week longer. 

A complete dislocation fomvard has been reported by Richmond; 1 the 
patient was a man, forty-seven years old, who fell upon his hand from a 
height of about nine feet. The hand, from the wrist to the knuckles, 
was very noticeably shortened; there was a prominent transverse ridge 
on the back of the wrist below the ends of the radius and ulna, and below 
this ridge was a marked depression. On the palmar aspect the base of 
the hand was unduly prominent, the general direction of the metacarpal 
bones being quite altered by their bases being pushed forward toward 
the palm. Both diameters of the wrist were increased ; voluntary flexion 
and extension were lost. The ends of the radius and ulna seemed sepa- 
rated somewhat from each other ; the transverse dorsal ridge could be 
demonstrated to be the first row of carpal bones with the semilunar 
unduly prominent ; between it and the radius and ulna flexion and ex- 
tension, although restricted, could be obtained with considerable ease and 
without crepitus. Below the ridge the extensor tendons could be plainly 
felt stretching across the depression to the fingers. None of the carpo- 
metacarpal joints had sustained any injury. On the palmar prominence 
the trapezoid could be felt placed more anteriorly than, and considerably 
above, the level of the trapezium ; and nearer the ulnar side the head of 
the os magnum could be felt slightly overlapping the ends of the radius 
and ulna, which on the palmar surface were quite obscured ; and on 
flexion and extension of the hand the os magnum could be felt to ride on 
their anterior surface. The displacement of the unciform, although dis- 
tinct, was much less marked. The examination showed that the second 
row of carpal bones was dislocated forward and upward from the first 
row, the displacement being most marked in the case of the os magnum 
and trapezoid. 

To these may be added a case briefly quoted by Malgaigne from the 
G-azette des Hojritaux, Nov. 20, 1829. A man's hand was caught in 
machinery, which dislocated it forward and lacerated all the soft parts of 
its back. Gangrene ensued, and death on the eighteenth day. At the 
autopsy two or three small bones, one of them broken, were found 
adherent to the bones of the forearm, and it was therefore supposed that 
the dislocation had taken place between the two rows of the carpus. 

Although the isolated dislocation of the different bones of the carpus 
is a rare injury, yet instances have been reported of the dislocation of 
almost every one of them. 

Scaphoid. — The only instances of dislocation of the scaphoid alone are 
two quoted by Cooper (loc. cit., pp. 432 and 436), one simple, the other 
compound. The former was reported by a medical student who was 
serving as "dresser" in the hospital, and as the symptoms are not de- 
scribed in detail some doubt must remain as to the accuracy of the 
diagnosis ; it was complicated by fracture through the lower articular 
surface of the radius. It is as follows : A woman, sixty years old, fell 
upon the back of her hand and " fractured the radius obliquely outward, 
through the lower articulating surface. The fractured portion, with the 

1 Richmond: Lancet, 1879, i. p. 844. 
24 



370 DISLOCATIONS AT THE WRIST. 

os scaphoides, was thrown backward upon the carpus. The wrist was 
slightly bent, and there was an evident projection at the back of the 
carpus." Crepitus was felt in moving the hand or the styloid process of 
the radius backward or forward. 

In the other the dislocation was compound, and the wound, which was 
caused by machinery, was so extensive as to make it the most prominent 
feature of the injury ; it extended through two-thirds of the circumference 
of the wrist ; the scaphoid projected at the back part, being attached only 
on the side toward the joint; the radial artery and the extensor tendons 
of the thumb, middle, and fore fingers were torn through. The scaphoid 
was removed. The patient recovered. 

A case of dislocation forward of the scaphoid complicating fracture of 
the lower end of the radius, in which the bone was removed through an 
incision, was reported by Cameron in the Glasgow Medical Journal, 
1878, p. 102 ; it is quoted in Fractures, p. 453. Six years later 
Cameron 1 again reported the case, this time as one of dislocation of the 
semilunar bone, but made no mention or explanation of the previous 
statement concerning it, although he described the case in the same terms 
as before. 

A case diagnosticated as a dislocation of the scaphoid and os magnum 
was reported by Dr. Morris, 2 house surgeon at Bellevue Hospital, but 
the symptoms on which the diagnosis was based are not described in 
sufficient detail to allow the diagnosis to be unhesitatingly accepted. The 
patient's hand had been forcibly extricated from between a heavy brush 
and roller ; it was " strongly adducted and rotated inwardly, with an 
unnatural projection at the carpus anteriorly;" the semilunar was in 
place, but freely movable. The displacement was easily reduced under 
ether ; it recurred as the patient was coming from under the influence of 
the ansesthetic, and was again reduced. The limb was placed in splints, 
and the patient made a fair recovery. 

A case (Fayne) in which the scaphoid and semilunar were together 
dislocated forward is briefly mentioned in the Revue de Therapeutique, 
March 15, 1887. The semilunar had undergone complete rotation and 
presented in a contused wound on the front of the wrist. 

Semilunar. — Nine cases of dislocation of the semilunar bone, one of 
them double (Flower), have been reported, including Cameron's case 
above mentioned. The cases are those of Mougeot, 3 Flower and Hulke, 4 
Erichsen, 5 Taaffe, 6 Chisolm, 7 Gross, 8 Buchanan, 9 and Albertin. 10 In five 
of them, Mougeot, Flower, Gross, Buchanan, and Albertin, the disloca- 
tion was compound, and in four of these the bone was removed ; the 
specimen of the fourth (Flower) is preserved in the museum of St. George's 

1 Cameron: Lancet, 1884, i. p. 885. 

2 Morris: N. Y. Medical Eecord, 1883, vol. xxiii. p. 376. 

3 Mougeot, quoted by Malgaigne. 

* Flower and Hulke: Holmes's Syst. of Surg., Am. ed., vol. i. p. 881. 

5 Erichsen : Science and Art of Surgery, Am. ed., 1873, vol. i. p. 421. 

6 Taaffe: Brit. Med. Journal, 1869, i. p. 335. 

* Chisolm : Philad. Med. Times, 1870 71, vol. i. p. 335. 

8 Gross : Philad. Med. Times, 1880-81, vol. xii. p. 220. 

9 Buchanan: Med. Times and Gazette, 1885, i. p. 113. 

10 Albertin:, La Province Medical e ; abstract in Lancet, July 23, 1887. 






DISLOCATIONS OF THE CARPAL BONES. 371 

Hospital. In two others, Cameron, Chisolm, the bone was removed 
through an incision made for the purpose. In every case the cause was 
a fall from a considerable height. In one case, Erichsen, the dislocation 
was backward, and in the other three simple cases, Taaffe, Cameron, 
Chisolm, and in three of the compound ones, Mougeot, Flower, Albertin, 
forward ; in neither of the other two compound cases is the direction of 
the displacement stated. Gross says the wound, half an inch long, was 
" on the inner side of the forearm anteriorly," and that ten days after the 
accident " a loose bone was detected in the wound toward the radial side 
of the wrist;" the injury was caused by jumping from a railway train 
in rapid motion, and Avhen the patient was seen, two days after the 
accident, the parts were so swollen that it was thought best to make no 
examination ; there was also fracture of both bones of the forearm four 
inches above the wrist. The wound suppurated for three months. 
Buchanan says there was a " deep, lacerated wound at the lower part of 
the forearm, just above the wrist. At the bottom of the wound, but 
superficial to the bones of the forearm, a small round bone was felt, and 
crepitus and abnormal mobility showed that the lower part of the radius 
was fractured." On the sixth day the bone was removed, and ten days 
later the limb was amputated because of diffuse suppuration. Examina- 
tion showed that "no other injury of the carpus had been sustained." 
Probably in both cases the dislocation was forward, and in Buchanan's 
also upward. 

Cameron's case, in which there was also a fracture of the lower end of 
the radius, is quoted in Fractures, page 453 ; in the report from which that 
quotation was made the dislocated bone was said to be the scaphoid ; the 
middle and ring fingers were strongly flexed, and the slightest attempt to 
extend them caused great pain. In Chisolm's the fingers were in forced 
flexion, and their extension was resisted and painful. In Cameron's 
the bone " was felt lying under the skin in the middle line of the front 
part of the forearm, about an inch above the flexure of the wrist;" in 
Chisolm's, " a large, rounded, hard, subcutaneous prominence existed on 
the front of the wrist, beneath the upper wrist fold, and directly over the 
site of the semilunar bone." The removal of the bone was made in each 
case because of the flexion of the fingers and the pain ; Cameron's patient 
made a good recovery ; the result in Chisolm's is not stated. 

In Taaffe's case, which was first seen ten months after the accident, 
" there was a dislocation of a single bone of the carpus which projected 
forward and upward between the radius and ulna ; it was not wedged 
between the bones, but projected in front of them on the anterior aspect 
of the limb. The radius and ulna were not displaced, nor was there any 
evidence of fracture." Reduction was effected by " strong extension and 
firm pressure." 

In the single case of backward dislocation, Erichsen, the patient had 
fallen from a height, doubling his right hand under him ; "a small hard 
tumor was felt projecting on the dorsal aspect of the wrist; it readily 
disappeared on extending the hand and employing firm pressure, but 
started up again so soon as the wrist was forcibly flexed. It was evident 
that the bone belonged to the first row of the carpus ; and from its size, 
its position toward the radial side of the carpus, and its shape, which 



372 DISLOCATIONS AT THE WKXST. 

could be very distinctly made out, there could be little doubt that it was 
the semilunar bone." 

The frequent association of a wound on the anterior aspect of the wrist 
and the nature of the cause, a fall from a height, make it probable that 
the dislocation forward is effected while the hand is in dorsal flexion, yet 
in Taaffe's case it was thought the blow was received upon the back of 
the hand. Corresponding to this relative frequency of dislocation of the 
semilunar forward (in fact, it is the only bone of the first row that has 
been dislocated without associated fracture of the radius), is the frequency 
of partial dislocation of the os magnum backward, and it seems probable 
that the two facts have a common cause in the relation of the two bones 
to each other. Flexion, and especially extension of the wrist, take place 
largely in the mediotarsal joint, which has much the character of a ball- 
and-socket joint, of which the head of the os magnum is the most pro- 
jecting point, and in so far as the forward movement is arrested by bony 
contact or ligamentous connection the semilunar would be the most likely, 
through its contact with the more freely moving head of the os magnum, 
to be affected and displaced. 

The prognosis is unfavorable : in two of the three simple forward cases 
it was deemed necessary to remove the bone in order to relieve the dis- 
ability ; in the third the result is not stated. Of the five compound 
cases there was profuse suppuration in two, leading to amputation in one, 
and partial ankylosis in the other ; one got well with a useful joint, one 
died of tetanus, and the fifth appears to have died, probably of associated 
injuries, as the fall was from a great height. 

Unciform. — The only recorded case of dislocation of the unciform 
bone is one very briefly reported by Buchanan i 1 a man fell from a rail- 
way car ; "he was found to have a simple luxation of the unciform bone 
anteriorly. It lay just beneath the skin, and its process could be dis- 
tinctly outlined. Reduction was effected by direct pressure on the bone 
while the borders of the hand were approximated." Considering that 
the case, if correctly diagnosticated, is unique, the brevity of the report 
is to be regretted. 

The pisiform has been reported dislocated in three cases : in two 
(Erichsen, Fergusson) by muscular effort ; in one (Gras, Gazette Medi- 
cate, 1835, p. 542) by the pressure of the hand upon a flat-iron while 
ironing clothes. In Erichsen's case the bone was drawn up the arm for 
a distance of nearly an inch. 

Os magnum. — Many authors speak of partial dislocation of the head 
of the os magnum backward as a not infrequent accident produced by 
prolonged, perhaps not violent, use of the hand, or by a sudden effort, or 
a fall. Malgaigne classifies the former as pathological dislocations ; they 
are characterized by the appearance on the back of the wrist just above 
the base of the third metacarpal bone of a small, hard, round lump, 
especially during palmar flexion, which appears more or less completely 
during dorsal flexion, and can sometimes be temporarily reduced by 
pressure. It ordinarily causes little or no disability. 

The more distinctly traumatic cases are those of Richerand (quoted by 

1 Buchanan : Philad. Med. and Surg. Keporter, 1881-82, vol. 46, p. 418. 



DISLOCATIONS OF THE CARPAL BONES. 373 

Cooper), Cooper (loc. cit., p. 434), and Seeger (quoted by Tillinanns). 
Richerand's patient was a woman who grasped the side of her bed during 
parturition, turning her wrist forward, and felt a sharp pain in the wrist. 
A fortnight later, a hard, circumscribed tumor was found at the back of 
the carpus, formed by the head of the os magnum, which was readily 
replaced by making gentle pressure on it, and extending the hand. 
Richerand had seen another similar case, as had also Chopart and Boyer. 

Cooper's patient was a young, muscular man, who had fallen upon his 
hand in such a w T ay as to bring the palmar aspect of the fingers into con- 
tact with the forearm. At the point of most pain was a round, hard 
tumor, rather larger than a marble, which produced a most evident 
deformity on the back of the wrist opposite to and above the base of the 
third metacarpal. The hand was slightly bent, and extension caused 
considerable pain ; the tendon of the extensor carpi radialis brevior was 
displaced slightly to the radial side ; the forefinger was abducted from 
the middle one, and any attempt to approximate them gave great pain at 
the base of their metacarpal bones ; and opposite the base of the middle 
one was a depression, quite evident to both sight and touch. Reduction 
was effected by making traction on the fore and middle fingers, while 
pressure was made upon the os magnum. On flexing the hand, the 
deformity was reproduced •; it was again corrected, and the hand placed 
in splints. 

Seeger 1 saw in 1829 and 1830 two cases of dislocation of the head of 
the os magnum backward caused in young men by falls upon the closed 
fist. Reduction was effected by traction and forcible flexion of the hand, 
in one case easily, in the other only after several attempts. The hand 
was kept in splints in the extended position from six to eight weeks, with 
compresses in front and behind. Recovery was complete. 

Trapezoid. — The diagnosis of dislocation of the trapezoid backward 
was made in a case reported by Gay ; 2 the patient was a man, thirty-two 
years old, and the injury was caused by striking with the fist in play. 
" At the base of the metacarpal bone of the index finger was a sharp, 
hard, slightly movable bunch, raised one-quarter of an inch, and tender 
on pressure." There was no crepitus ; the metacarpal bones were of the 
same length. It could not be reduced. Two months later the deformity 
was unchanged, but the hand had become nearly as good as the other. 

Trapezium. — Two cases of dislocation backward of the trapezium alone 
have been reported by Uhde 3 and von Mosengeil. 4 

Uhde's patient was a man, thirty-three years old, who had been knocked 
down by a wagon. The right thumb and the region of its metacarpal 
bone was bruised, swollen, and painful, and " at the junction of the first 
metacarpal and trapezium an unusual mobility of the latter bone was 
recognizable, and instead of the normal depression between the tendons 
of the extensor secundi and extensor primi internodii on extension of the 
hand there was to be seen a small angular tumor corresponding to the 
trapezium, which projected on flexion of the first and second metacarpals 

1 Seeger: Mittheilungen der Wiirtt arztl. Vereins, vol. i., quoted by Tillmanns. 

2 Gay: Boston Med. and Surg. Journ , 1869, vol. 81, p. 188. 

3 Uhde : Deutsche klinik, 18£0, ii. p. 539. 

4 Yon Mosengeil: Arch, fur klinische Chirurgie, 1871, vol. 12, p. 723. 



374 DISLOCATIONS AT THE WRIST. 

about three and a half lines above the level of the back of the hand, and 
disappeared on straight extension of these bones with a creaking sound. 
Six months later the trapezium was found to project one and a half lines 
on the radial side." 

Von Mosengeil's patient had a deformed hand, the thumb and its 
metacarpal bone having the shape and position of a finger ; the displace- 
ment, half a centimetre, was produced by a blow received upon the palm 
of the hand ; it was reduced by flexion and pressure. 

Os magnum and trapezoid. — Uhde (loc. cit.) briefly describes under the 
title " luxatio ossis multanguli minoris et ossis capitati" a case of injury 
to the wrist marked by a projection on the back of the hand which he 
attributed to the displacement of the trapezoid and os magnum. The 
injury was caused by a fall upon <c the anterior ends of the metacarpal 
bones." It does not appear from the description whether the bones were 
thought to be dislocated from the metacarpals as well as from the first 
row of the carpus. The prominence could be reduced by pressure, and 
reappeared on flexion of the wrist. 

A case reported by Alqui6, of Montpellier, has been frequently quoted ; 
there was much displacement of the carpal bones on the radial side, but 
not .only was its character uncertain, but in addition the region had 
suffered from two different accidents, one of which was accompanied by 
great laceration of the soft parts. 

D. Carpo-metacarpal Dislocations. 

Cases have been reported of the isolated dislocation of every one of the 
metacarpal bones except the fifth, and of the combined dislocation of two 
or more. 

First metacarpal. — Dislocations of the metacarpal bone of the thumb 
are the most frequent and important ; almost all have been backward. 

Very little is known of dislocations forward. Sir Astley Cooper (loc. 
cit., p. 443) says, " In the cases which I have seen of this accident the 
metacarpal bone has been thrown inward, between the trapezium and the 
root of the metacarpal bone supporting the index finger ; it forms a pro- 
tuberance toward the palm of the hand ; the thumb is bent backward and 
cannot be brought toward the little finger." Poinsot quotes a reference 
by Vidal de Cassis to a case of incomplete dislocation forward which he 
had easily reduced. 

Albert 1 saw two cases of incomplete dislocation outward; one was old, 
the other recent. In the latter the injury was produced in a trial of 
strength by grasping hands. The base of the first metacarpal projected 
partly on the radial side, and the long axis of the bone was directed 
obliquely downward and outward. The displacement was easily reduced, 
but immediately recurred. After reduction the thumb was fixed in ab- 
duction by a silicate dressing and so maintained for six weeks. Complete 
recovery. 

The displacement in Michon's 2 second case is not entirely clear ; he 

1 Albert : Chirurgie, vol. 2, p. 445. 

2 Miction: Bull, de la Soc. de Chirurgie, 1848, vol. i. p. 11. 



CARPO-METACARPAL DISLOCATIONS. 375 

speaks of it as an incomplete dislocation inward, but Malgaigne describes 
it as incomplete backward* and inward. 

Dislocations backward may be complete or incomplete ; of 16 cases 
collected by Boyer 11 were incomplete, 5 complete. The cause may be 
a forced flexion of the thumb into the palm of the hand, or its forced 
movement in the opposite direction, or direct violence received upon the 
thenar eminence, as in striking upon the handle of a chisel, or in striking 
a blow with a hammer, or in the bursting of a gun. 

Specimens of old dislocation have been dissected by Foucher 1 and 
Gerin-Roze; 2 in the former the upper end of the metacarpal bone was 
displaced backward and a little inward, and was flexed at a right angle 
to and fused with the trapezium ; in addition, the second metacarpal 
was displaced upward about two centimetres on the back' of the wrist, 
retaining the insertion of the extensor carpi radialis, and the third meta- 
carpal had been broken at its middle. The injury was caused by the 
bursting of a gun. In Gerin-Roze's case the displacement was directly 
backward, the anterior edge of the base of the metacarpal resting upon 
the posterior edge of the inferior articular surface of the trapezium ; 
incomplete reduction could be made. 

In the incomplete form the posterior edge of the base of the metacarpal 
bone can be seen and felt in the interval between the tendons of the 
extensor primi and extensor secundi internodii as a hard lump continuous 
with the shaft of the bone and reducible by pressure. The thumb is 
generally somewhat flexed toward the palm, but may be extended or 
"straight." Movement is limited and painful, and flexion increases the 
apparent displacement. 

In the complete form the dorsal prominence is more distinct, and rests 
upon the trapezium which forms a recognizable lump in the ball of the 
thumb. The thumb is shortened by the ascent of the metacarpal bone, 
its first phalanx appearing in consequence to have passed upward into the 
thenar muscles, and it is usually flexed at the carpo-metacarpal joint. 

In some, even recent, cases reduction has been impossible, but usually 
it has been effected without difficulty by traction on the thumb and direct 
pressure forward and downward upon the projecting end of the bone. 
Early recurrence has been noted in some cases, and in a fjw prevention 
of recurrence has been difficult or incomplete. Moulded splints of leather 
or gutta-percha, and pasteboard or wooden splints with compresses at 
the back of the joint, are ordinarily used, and have given satisfactory 
results. In one case, the only dressing consisted of strips of adhesive 
plaster, running from the back of the forearm around the ball of the 
thumb, and back between it and the index finger to the forearm, so as to 
maintain the member abducted and extended. 

The restoration of function after reduction is complete, and even when 
the dislocation has remained unreduced some patients have been able to 
make good use of the thumb ; in others, the movement of adduction and 
opposition has been much restricted. 

The second metacarpal has been reported dislocated forward in two 

1 Foucher: Bull, de la Soc. Anatomique, 1856, p. 6. 

2 Gerin-Roze: Bull, de la Soc. Anatomique, 1858, p. 266. 



376 DISLOCATIONS AT THE WRIST. 

cases, and backward in five cases ; in one of the latter, together with dislo- 
cation of the first, and in another with dislocation of the third. An addi- 
tional case, observed by himself, is mentioned by Demarquay, 1 in which 
the first and second were together dislocated, but the direction is not 
stated, and no details are given. 

The forward cases are those of Bourguet (quoted by Malgaigne) and 
Marsh (quoted by Hamilton). In Bourguet's, the cause was excessive 
pressure on the upper posterior part of the bone; in Marsh's, it was an 
oblique blow with a hammer on the back of the clenched hand. In both 
cases the proximal end of the bone could be felt in the palm, and a corre- 
sponding depression on the back ; in the former case, the lower end of the 
bone was inclined forward, and the finger appeared shortened nearly one- 
fourth of an inch. Both were easily reduced by traction on the finger 
and pressure on the end of the bone. 

The uncomplicated backward cases are those of Hamilton (loc. cit., p. 
724) and Humbert ; 2 the former was caused in a woman, twenty-eight 
years old, by a fall upon the closed hand. Reduction was easily effected. 
Humbert's patient was a man thirty years old, who was kicked by a horse 
upon the hand that held the reins, the blow falling on the back of the 
lower end of the second metacarpal bone and the adjoining phalanx ; the 
upper end of the bone could be felt as a hard, circumscribed prominence 
on the back of the hand, and the finger, measured by the adjoining one, 
appeared five millimetres short. Reduction was made by traction and 
direct pressure downward and forward. Apparently the dislocation had 
been caused by forced palmar flexion of the bone. 

The case in which the dislocation was associated with that of the first 
metacarpal is that of Foucher, mentioned above. 

In two cases seen by Hamilton there was incomplete dislocation back- 
ward of the upper end of the second and third metacarpals, caused by 
striking a blow with the fist ; in both cases the dislocation was old, and 
had persisted in spite of attempts to maintain reduction. 

Third metacarpal. — In addition to these two cases, in which the injury 
was associated with dislocation of the second metacarpal, dislocation back- 
ward of the third metacarpal has been observed by Blandin 3 and Roux. 4 
Blandin's patient fell, while holding a roll of paper, and struck his head 
against a post ; the blow was slight, and caused no pain at the time, but 
the middle finger promptly became powerless, and the hand numb and 
swollen. There was a linear transverse ecchymosis at the back of the 
first phalanx of the middle finger, close by the metacarpal joint, and, on 
movement, a crackling that resembled crepitation. No other symptoms 
are mentioned. Blandin made the diagnosis of "diastasis or incomplete 
dislocation" of the third metacarpal bone, but others who saw the case 
thought the bone was broken. The title of the report of the case is 
" incomplete dislocation upward." 

Roux's patient had been injured in a mine explosion ; a hard, circum- 
scribed, subcutaneous tumor could be seen and felt on the back of the 

1 Demarquay: Bull, de la Societe de Chirurgie, 1851, vol. 2, p. 171. 
J Humbert : Union Medicale, 1868, vol. 5, p. 527. 

3 Blandin : Gazette des Hopitaux, 1844, p. 552. 

4 Roux: Union Medicale, 1848, p. 224. 



CARPO-METACARPAL DISLOCATIONS. 377 

wrist, continuous and moving with the third metacarpal ; the middle 
finger was shortened. The dislocation was reduced by direct pressure, 
but appears to have recurred, for at the autopsy the base of the bone was 
found resting on the back of the os magnum ; the second metacarpal was 
broken. 

An incomplete backward dislocation of the fourth metacarpal was 
reported by Maurice. 1 It was caused by the premature explosion of a 
cartridge which the patient was putting into a Chassepot gun ; the plunger 
was driven backward against the palm of the hand. There was a promi- 
nence half a centimetre high on the back of the hand, corresponding to 
the upper end of the fourth metacarpal. Reduction was easy, and 
recovery prompt. 

The four inner metacarpal bones (II., III., IV., V.) have been simul- 
taneouly displaced in four cases, Vigouroux, 2 Hamilton, 3 Tillaux, 4 and one 
of my own ; in the first and second the dislocation was backward, in 
Tillaux's and mine forward. 

Vigouroux's patient was injured when eighteen years old, by the explo- 
sion of a pistol, which he held in his left hand. At his death, at the age 
of sixty-two years, there was found a complete dislocation backward of 
the last four metacarpal bones ; these bones were flexed forward and the 
first phalanx of each of the last three fingers was incompletely dislocated 
backward. The index finger and the lower part of its metacarpal bone 
were lacking. All the joints of the carpus, including that of the trape- 
zium and first metacarpal, were normal. 

Hamilton's patient was struck at the battle of Fredericksburg by a ball 
which entered at the ulnar side of the hand and crossed the back of the 
wrist between the last row of carpal bones and the skin. When seen by 
Hamilton five years later " the displacement (backward) was very con- 
spicuous ; no fragments of bone had ever escaped. The movements of 
all the fingers, except the index and little fingers, were unimpaired." 

Tillaux's patient, whom I had the good fortune to see when he was 
admitted to the Lariboisiere hospital, was twenty years old ; twelve days 
before admission to the hospital he had fallen backward from a window, 
about ten feet, striking upon the back of his flexed hand. The hand 
was flexed on the wrist and could not be actively extended. There was 
a dorsal depression corresponding to the line of junction of the carpal 
and metacarpal bones, sharply limited above by a transverse prominence 
which was evidently formed by the second row of the carpus, and on the 
palmar surface at the same level the ball of the hand was more promi- 
nent than usual. The relations of the first metacarpal with the trapezium 
were unchanged. Moderate traction with direct pressure forward reduced 
the displacement with a click, and by making pressure in the opposite 
direction it was again produced. After a second reduction the limb was 
immobilized for a fortnight. Complete recovery. 

My patient was a lad fifteen years old who was admitted to the Pres- 

1 Maurice: Gazette Medicale, 1868, p. 587. 

2 Vigouroux: Bull, de Societe Anatomique, 1856, p. 15. 

3 Hamilton : Loc. cit. , p. 724. 

4 Tillaux : Bull, de la Societe de Chirurgie, 1875, p. 415. 



378 DISLOCATIONS AT THE WRIST. 

byterian Hospital in January, 1887, after having fallen down an elevator 
shaft, a distance of about forty feet, and received a compound fracture of 
the right forearm, a severe injury of the right hip, the nature of which 
could not be satisfactorily made out, and a dislocation of the left carpo- 
metacarpal joints. When I first saw the patient, three weeks later, the 
last-named injury had not been recognized. The hand was then in 
almost complete extension on the wrist and occupying a plane somewhat 
anterior to that of the wrist and forearm. The back of the wrist formed 
a rounded, resistant prominence, continuous above with the back of the 
radius and ulna and terminating below in a sharp, well-defined transverse 
ridge which extended completely across from the fifth to the second meta- 
carpal and curved upward on the outer side toward the styloid process of 
the radius. The finger, passed upward along the back of the metacarpus, 
was arrested by this ridge, which appeared to be about one-quarter of an 
inch high and corresponded to the line of the carpo-metacarpal joints. 
The first row of carpal bones was in normal relations with the forearm 
and with most of the second row, but the relations of the trapezium 
could not be clearly made out. I was under the impression that it was 
displaced somewhat forward from the scaphoid, it had preserved its rela- 
tions with the first metacarpal bone. The ball of the hand was abnor- 
mally prominent, and the antero-posterior diameter of the wrist appeared 
thereby increased ; the transverse diameter was unchanged. 

The deformity was easily reduced by traction and direct pressure, but 
immediately recurred when the pressure was removed. Reduction was main- 
tained for ten days by keeping the limb in a plaster-of-Paris dressing ; on 
removal of the dressing the deformity did not recur, but a few hours 
later the patient reproduced it while experimenting to ascertain if the 
reduction was permanent. It was again reduced, and the limb dressed 
as before. Three weeks later the reduction was complete and permanent 
except for some projection forward of the first metacarpal and trapezium, 
and the wrist and fingers had regained their mobility. 

Dislocation of all five metacarpals. — Poulet 1 reported a case of 
incomplete dislocation forward of all five metacarpal bones ; the injury 
was caused by a fall from a horse and was associated with a wound of the 
skin on the ball of the hand and slight chipping of the anterior edges of 
the carpal bones. The swelling and the inflammatory reaction were so 
great that an examination was not made until after the lapse of a month. 
There was then found on the back of the hand a projection formed 
mainly by the os magnum, and below it a depression extending from the 
trapezium to the unciform. On the palmar surface the ball of the hand 
projected forward, the palmar fold was effaced, and a deep, ill defined 
bony prominence could be felt. The interdigital spaces were two 
centimetres nearer the styloid processes than on the other hand. Partial 
reduction and restoration of mobility were obtained. 

Erichsen gives a woodcut and description of a plaster cast in the 
University College Museum, London, taken from a patient in whom he 
thinks this dislocation must have existed ; and Rivington 2 reported the 

1 Poulet : Bull, de la Soc. de Chir., 1884, p. 902. 

2 Kivington : Lancet, 1873, I. p. 270. 



CARPO-METACARPAL DISLOCATIONS. diV 

case of a patient who had been run over by a wagon and had sustained 
a compound dislocation forward of all the metacarpal bones, the base of 
the third projecting through a transverse wound near the centre of the 
palm ; the first phalanx of the thumb also was dislocated, and the index 
finger so injured that its amputation was necessary. The base of the 
third metacarpal was excised and the dislocation reduced. After 
dangerous supination and high fever the patient recovered with a fairly 
useful hand. 



CHAPTER XXIII. 

DISLOCATIONS OF THE THUMB AND FINGERS. 

The tables in Chapter I. show that dislocations of the thumb and 
fingers in combined hospital and polyclinic services amount to nearly ten 
per cent, of all dislocations, and that only about half of them are treated 
in hospital. Of these the dislocations of the thumb, or even of its proxi- 
mal phalanx alone, are much the most numerous, but the details of the 
statistics are not sufficient exactly to determine the relative numbers. 
Polaillon 1 gives the largest statistics of which I have knowledge, 206 
cases, divided as follows : 

Dislocation of the 1st (proximal) phalanx of the thumb . . 84 

1st phalanx of other ringers . . .27 

2d (middle) phalanx . . . . .26 

3d (terminal) " . . . . . 69 

206 

He does not state whence these statistics are derived, but it is probable 
he made them up, as he did those of other joints, from cases reported in 
text-books and journals, and, therefore, they have not quite the same 
value in determining the relative frequency of the different varieties, as 
if they had been made up from the integral statistics of hospitals, dispen- 
saries, or individual surgeons. For the same reason the mortality, 10 
cases of the 206, or 4.85 per cent., cannot be accepted as that of the 
injury in general, since exceptional cases are more frequently reported 
than the commonplace ones. A special cause of danger, one that may 
make the rate of mortality higher than that of other dislocations, is found 
in the fact that compound dislocations are comparatively numerous, and 
are exceptionally liable to be followed by tetanus. 

Dislocations of the proximal phalanx of the thumb. 

These dislocations are not only the most frequent of those involving 
the phalanges, but they also derive a special interest from the frequency 
with which the reduction has been found to be very difficult or has entirely 
failed. The cause of this difficulty has been the subject of much study 
and experiment upon the cadaver during the last hundred years, which 
may be said to have culminated in an elaborate paper read by Farabeuf 2 
before the Societe de Chirurgie of Paris in 1875, in which the anatomy 
of the joint was described with much detail. This description and his 
explanation of the cause of the difficulty have been generally copied and 
accepted by writers in Germany and France. 

1 Polaillon : Diet. Encyclopedique des Sciences Med., article Doigt, p. 166. 

2 Farabeuf: Bull, de la Societe de Chirurgie, 1876, p. 21. 



DISLOCATIONS OF PKOXIMAL PHALANX OF THUMB. 881 

Anatomy. — The head of the metacarpal bone presents no expansion 
on the dorsum, and but little, if any, on the sides, but on its palmar aspect 
it projects in the form of a well-rounded tubercle or condyle covered with 
cartilage for articulation with the two sesamoid bones, which are developed 
in the combined anterior ligament and the tendons of the short muscles 
that are attached to the base of the phalanx. Of these two sesamoid 
bones the outer is the larger, and both are firmly and closely united to 
the phalanx by ligaments which are continuous with each other across 
the front of the joint, and together form the "glenoid ligament" which 
separates the tendon of the long flexor of the thumb from the joint, and 
is continued backward and upward to the palmar surface and sides of the 
metacarpal bone. These ligaments hold the sesamoid bones close to the 
phalanx and, allowing them to turn freely in the direction of flexion, 
prevent their movement in the opposite direction beyond a line parallel 
to the long axis of the phalanx, so that if the latter is separated from 
the metacarpal bone the sesamoid bones cannot be turned up against the 
articular surface of the phalanx. The arrangement has been aptly com- 
pared to that of the hinged side of a table, which can be let down but 
-cannot be raised above the level of the. top of the table. The connection 

Fig. 103. 






The metacarpophalangeal joint of the left thumb. (Farabeuf.) A. The external lateral ligament. 
B. The internal lateral ligament. C. Palmar aspect. 



of the sesamoid bones is much stronger with the phalanx than with the 
metacarpal bone. In addition, there are the lateral ligaments uniting 
the phalanx and metacarpal bone. The head of the metacarpal bone is 
more prominent anteriorly on the outer than on the inner side, and the 
tendon of the flexor longus pollicis lies nearer the inner than the outer 
side. This tendon is lodged at its lower end in a firm sheath, which 
extends upward to, and is connected with, the sesamoid bones. 

The muscles which are attached to the first phalanx are the abductor, 
adductor, and flexor brevis ; the latter has two insertions, one upon the 
outer the other upon the inner side of the base of the phalanx, and the 
two sesamoids are developed within its tendons of insertion where they 
are continuous with the anterior ligament ; the outer insertion spreads to 
each side of its sesamoid bone, and is attached also to the palmar surface 
of the base of the phalanx and to the external lateral ligament, covering 
in a large part of the palmar and external faces of the joint. The 
abductor is attached to the external sesamoid by deep tendinous fibres, 
and also to the intersesamoid ligament, and by expanded fibres to the 



882 



DISLOCATIONS OF THE THUMB AND FINGERS. 



outer side of the phalanx and the extensor tendons, after the manner of 
insertion of the interosseous muscles in general. The adductor is in like 
manner attached to the internal sesamoid bone and the inner side of 
the phalanx and the extensor tendon. These attachments and muscles 
are made tense . by abducting the thumb, and are relaxed by pressing 
the metacarpal bone into the palm of the hand. The long flexor and 
the extensors are relaxed by inclination of the hand toward the radial 
side. Consequently, to relax as much as possible the various muscles 
attached to the thumb, the hand should be held in straight extension 
and slight abduction, and the thumb should be pressed into the palm, 
adduction. 

The dislocation may be forward or backward, complete or incomplete. 

Backward dislocations. — -This is the most frequent form, and the one 
in which reduction of the dislocation is often difficult. * 

The common cause is exaggerated dorsal flexion of the first phalanx. 
When the normal limit of the movement is reached the anterior ligament 
is put upon the stretch and, the movement being continued, yields at its 
attachment to the metacarpal bone, so that the sesamoid bones accompany 
the phalanx in its movement. 

a. Incomplete form. — If this movement is not carried further than to 
the position shown in Fig. 104 the articular end of the phalanx rests 



Fig. 104. 



Fig. 105. 




Incomplete dislocation of the thumb. 



Incomplete dislocation. (Farabeuf.) 



against the posterior margin of the head of the metacarpal bone, and is 
maintained in this position by the tension of the portions of the adductor 
and abductor muscles which are attached directly to the phalanx, for their 
line of traction is now posterior to and above the new centre of motion. 
The attitude of the member is represented in Fig. 105. 

This incomplete form is the one which many people, especially the 
young, can voluntarily produce by contracting the extensor muscles. 
The anterior ligament and the sesamoid bones rest like an apron against 
the antero-inferior articular surface of the metacarpal bone, and the dis- 
location can be readily reduced by moderate traction upon the phalanx and 
flexion. 

b. Complete form. — If, however, the movement is carried further, the 
phalanx entirely leaves the articular surface of the metacarpal bone, and 






DISLOCATIONS OF PROXIMAL PHALANX OF THUMB 



38S 



Fig. 106. 



moves upward on its dorsum, being followed by the anterior ligament 
and the sesamoid bones (Figs. 106, 107, 108). The external lateral 
ligament is torn, and usually the internal 
one also ; the tendon of the flexor longus 
pollicis may remain in position, and be 
tightly stretched across the articular face 
of the metacarpal bone, as has been seen 
in some compound dislocations (e. g., Es- 
march 1 ), or, and more commonly, it accom- 
panies the inner sesamoid bone to the inner 
side of the metacarpal ; occasionally it 
passes to the outer side of the metacarpal 
bone, accompanying the external sesa- 
moid, but probably it does so only when, 
in the production of the dislocation, the 
thumb is bent to the outer side as well as 

backward. The head of the metacarpal bone projects through the rent 
in the capsule, and the tendons of the adductor, abductor, and the two 
portions of the flexor brevis rest against its sides. The phalanx stands 




Simple complete dislocation of the thumb. 
(Farabetjf.) 



Ftg. 107. 




Simple complete dislocation ; outer side. (Farabetjf.) 

erect upon the dorsum of the metacarpal bone, being held there by the 
tension of the abductor and adductor. The dislocation is sometimes 
made compound by the rupture of the soft parts on the palmar aspect of 
the joint. 

The appearance of the member is characteristic (Fig. 109). The phalanx 
is thrown back vertically upon the metacarpal bone, and the latter is 
adducted, the thenar eminence being consequently increased in thick- 
ness and diminished in breadth. The head of the metacarpal bone pro- 
ects in front as a round, smooth prominence close under the skin, over 



1 Esmarch : Berlin, klin. Wochenschrift, 1876, p. 629, first case. 



384 



DISLOCATIONS OF THE THUMB AND FINGERS. 



which the tendon of the long flexor may perhaps be felt. The phalanx 
is quite movable from side to side, and can be rotated ; it can also be 



Fig. 108. 



Fig. 109. 





Simple complete dislocation. (Farabeuf.) 
Simple complete dislocation ; right 

thumb. The long flexor tendon is turned down so as to be parallel with the 
displaced to the inner side (fara- metacarpal bone, but this movement should 
BEUF '' not be made, lest it should increase the diffi- 

culty of reduction by effecting a change into the " complex" form. 

c. Complex form. — Under this title Farabeuf places those cases in 
which, usually because of injudicious attempts to reduce, the phalanx has 

Fig. 110. 




Complex dislocation. (Farabeuf.) 



been lowered until it is nearly or quite parallel to the long axis of the 
metacarpal bone, and in which, in consequence, the sesamoid bones have 



Fig. 111. 




Complex dislocation of the thumb ; outer side. The hook raises the periosteal continuation of the lateral 
ligament, exposing the reflected sesamoid bone. (Farabeuf.) 

been turned upward, and lie on the dorsum of the metacarpal bone above 
the base of the phalanx (Figs. 110, 111). The attached muscles are 
correspondingly displaced along the sides of the metacarpal bone, and 



DISLOCATIONS OF PROXIMAL PHALANX OF THUMB. 



385 




Complex dislocation. (Fakabklt.) 



grasp it more or less tightly, and the tendon of the long flexor accom- 
panies one of the sesamoids, usually the internal one. If the phalanx is 
now turned back, so as to 
stand at right angles to the 
metacarpal bone, its articular 
surface is separated from the 
latter by the interposed sesa- 
moids. 

The appearance of the 
hand is represented in Fig. 
112 ; the thumb is nearly 
parallel to the metacarpal 
bone, the base of the phalanx 
can be felt upon the dorsum 
of the latter, and the head of 
the latter can be felt in front 
as in the .preceding form. 
The characteristic symptom of this variety is the straight extension of 
the thumb. 

Treatment. — Although an incomplete dislocation can be readily reduced 
by traction and flexion, yet it is better, unless the diagnosis of the variety 
is beyond question, to act as if the dislocation was complete, for prema- 
ture flexion — that is, flexion before the phalanx has been brought fully 
down to the end of the metacarpal bone, may transform a simple complete 
dislocation into a complex one, and thereby materially add to the diffi- 
culty of reduction. The obstacles in the simple complete form arise from 
the tension of the muscles attached to the side of the phalanx, by which 
they are made to clasp the projecting end of the metacarpal bone tightly, 
and to the tension of the tendon of the long flexor, when this also is dis- 
placed. In a compound dislocation treated by Wordsworth 1 it was thought 
necessary to divide this tendon ; reduction was then easily made. In 
another, with a similar wound at the front of the joint, treated by 
Esmarch, the opening in the capsule was first enlarged by nicking at 
each angle, and then, as reduction still failed, a blunt hook was intro- 
duced at each ano-le, and the lateral ligaments and sesamoid bones drawn 
aside, and reduction was at once made. 

Such cases and consideration of the anatomical conditions indicate the 
measures to be taken in simple cases. The metacarpal bone should be 
pressed toward the palm to relax the short muscles, and pressure made 
against the front of its head while the surgeon holds the phalanx in rec- 
tangular dorsal flexion and presses its base downward with his thumbs 
close along the dorsum of the metacarpal bone to its head, and then gently 
flexes it into place. If this fails, traction with a cord passed around the 
back of the phalanx close to its base may be substituted for the pressure 
of the surgeon's thumbs, or, when the phalanx has been brought close to. 
its place, it may be slightly moved toward the inner side and rotated, 
turning the palmar surface outward, so as to turn the tendon of the long 
flexor and the internal portion of the capsule and adductor tendon past 



1 Wordsworth : Lancet, 1863, ii. p. 443. 
25 



386 



DISLOCATIONS OF THE THUMB AND FINGERS 



Fig. 113. 



the inner side of the head of the metacarpal bone, and then moved 
toward the outer side and rotated in the opposite direction to free the outer 
bands. Of course, if the phalanx is displaced rather to the outer than to 
the inner side, so that it is probable that the long flexor tendon has been 
displaced on that side, the order of this successive freeing must be changed, 
and the external bands first brought into place. 

If the sesamoid bones have been turned upward (complex form) the 
phalanx must be brought again into rectangular dorsal flexion, and then 
moved downward as before, but it will be necessary to move it further, so 
that the upper edge of the sesamoids and the transverse torn edge of the 
attached anterior ligament may be brought completely past the edge of 

the head of the metacarpal bone. 
This requires the exercise of more 
force, and for this purpose Fara- 
beuf recommends a forceps which 
he has successfully employed in 
several cases, and which is suf- 
ficiently shown in Fig. 113. Levis's 
instruments (Figs. 114 and 115), 
placed against the back of the pha- 
lanx, held at right angles to the 
metacarpal bones, and used to push, 
not to pull, the thumb downward, 
would probably be equally efficient, 
and could be readily made when 
wanted. 

In the simple complete form the 
phalanx must be kept closely 
against the metacarpal bone during 
the manipulation in order that it 
shall certainly push the sesamoid 
bones before it ; and in the com- 
plex form the position of rectangu- 
lar dorsal flexion is equally neces- 
sary, in order that the resistance of 
the untorn soft parts may be dimin- 
„ . ., . . _ . .. **.,-+. ished. A glance at Figs. 116 and 

Farabenf s instrument for reduction of dislocation & & . - , 

of the thumb. 117 shows how great a separation 

between the phalanx and metacar- 
pal bone is necessary to free the sesamoids when traction is made in 
straight extension, and how easily, even then, flexion of the phalanx may 
still leave them interposed between the joint surfaces. 

Fig. 114. 





Levis's instrument for making traction in reduction of dislocations of the phalanges. 



DISLOCATION'S OF PROXIMAL PHALANX OF THUMB. 



387 



In compound cases advantage may be taken of the wound, which is in 
the palmar aspect of the joint, and is produced by overstretching of the 



Fig. 115. 




Levis's instrument ; faulty method of use. 



soft parts, to act directly upon the tendons and ligaments, and draw them 
aside from the head of the metacarpal bone by blunt hooks, as in Esmarch's 
case above mentioned. 




Position of sesamoid bones during forcible traction. (Faeabeuf.) 

In several cases surgeons have found it necessary to make subcutaneous 
section of the bands on one or both sides, or to do an open arthrotomy, 

Fig. 117. 




Interposition of the sesamoid bones by premature flexion. (Faeabeuf.) 

making an incision upon one side, the inner, usually, of the dorsum, or 
on the front in the place usually occupied by the wound in compound 
cases, through which the tendon of the long flexor and the sesamoids are 
drawn forward into place. Such cases have, as a rule, done well under 
antiseptic treatment, but it is to be hoped, and perhaps expected, that 
resort to a cutting operation will be even more rarely had in the future 
than in the past, and that the cases left unreduced will be fewer. 

The prognosis in the past has not been favorable. Polaillon, analyzing 
58 cases, found that reduction had failed in 11 and had been effected 
only after numerous and prolonged attempts in 16 ; in 8 the dislocation 
was compound, and in 3 of these the head of the metacarpal bone was 
excised. In one case (Bromfield), nearly a hundred years ago, such 



388 DISLOCATIONS OF THE THUMB AND FINGERS. 

violent traction was made that the terminal phalanx was torn off; the 
ease has been persistently quoted as a warning ever since, but if it is 
remembered that traction is especially ill-adapted to effect reduction in 
difficult cases the warning will not be longer needed. In other cases the 
thumb has become gangrenous in consequence of the violence inflicted 
upon it by the traction, and in one of them (Dupuytren) pyaemia ensued 
and the patient died. 

In the cases in which the dislocation has been left unreduced and the 
phalanx has been lowered to a position in which it is parallel with the 
metacarpal bone, the usefulness of the member has been in great part 
restored, although, of course, the deformity persisted and the joint was 
immovable. 

Forward dislocations. — These dislocations, much rarer than the pre- 
ceding and less difficult to reduce, result usually from a fall or blow upon 
the back of the flexed phalanx — that is, by exaggerated palmar flexion, 
but in at least one case (Lombard) from exaggerated dorsal flexion pre- 
sumably combined with direct impulsion of the phalanx toward the palm ; 
according to Foucart's 1 experiments dorsal flexion needed to be combined 
with forced abduction in order to rupture the internal lateral ligament. 

The pathology has been shown by six autopsies, Wood, 2 Meschede, 3 
Foucart, two cases, Eve, 4 and one of my own not before reported. In 
two of these (Foucart, Eve) the injury was recent; in Meschede's it had 
lasted forty-eight days ; and in Foucart's second case, in Eve's, and in 
mine it was of long standing. The recent cases show, as is also found in 
experiments upon the cadaver, that the posterior and lateral parts of the 
capsule are torn, including the lateral ligaments, but that the connection 
between one or both sesamoid bones and the metacarpal bone may persist. 
The extensor tendons may be stretched directly over the projecting head 
of the metacarpal bone or they may be deviated to either side ; in my 
case the tendon of the extensor primi internodii appeared to have been 
detached and retracted. The base of the phalanx lies against the anterior 
surface of the metacarpal bone and, in recent cases at least, does not 
appear to be notably displaced upward; it may lie directly in front, or 
be somewhat displaced to either side, and the phalanx may be in straight 
extension or partly flexed. 

In the older cases a more or less complete nearthrosis forms between 
the bones, and fibrous bands and bony outgrowths give the joint sufficient 
solidity to make it useful. 

The specimen which is in my possession was taken from a patient who 
died in the Presbyterian Hospital, and is without history, although plainly 
of very long standing. There is but little overriding of the bones, which 
are firmly bound together, and the phalanx overlaps the metacarpal bone 
on its outer side by about one-third of its breadth, is flexed at an angle 
of 45°, and is slightly adducted. On the palmar surface of the 
metacarpal is a stout overgrowth of bone forming a sort of buttress 

1 Foucart: These de Paris, 1876, No. 199; quoted by Poinsot. 

2 Wood: Trans. Path. Soc. of London, 18-53, vol jv. p. 250. 

3 Meschede: Virchow's Archiv, 1866, vol. xxxvii. p. 510. 
* Eve: Lancet, 1880, i. p. 133. 



METACAKPO-PHALANGE AL DISLOCATIONS. 389 

against which the upper ends and part of the posterior surfaces of the 
sesamoid bones rest ; the tendon of the extensor secundi internodii passes 
obliquely downward and forward along the outer side of the metacarpal 
bone, lying in a deep bony groove of new formation more than an inch 
in length. The metacarpal articular surface is obliterated by adherent 
fibrous tissue ; that of the phalanx preserves its cartilage, though much 
thinned, and forms part of a joint cavity the remainder of which is con- 
stituted by a thick layer of fibrous tissue interposed between the two 
bones. A similar groove lodging the extensor tendons existed in Wood's 
specimen, and was thought to have resulted from a fracture. 

Symptoms. — The deformity is characterized by the position of the 
phalanx in front of the metacarpal bone, the projection of the head of the 
latter on the dorsum of the member, and the rather deeply placed promi- 
nence formed by the base of the phalanx at the lower part of the thenar 
eminence. The thumb appears in some cases to have undergone slight 
rotation about its long axis, and the attempt has been made to show a 
connection between the direction of this rotation and that of the lateral 
displacement of the extensor tendons ; that is, it has been claimed that 
when the rotation is such that the nail looks outward the tendons have 
been displaced toward the outer side, and vice versa. 

In one reported case the dislocation was made compound by rupture 
of the soft parts covering the back of the joint; recovery was delayed by 
a phlegmon of the ball of the thumb. 

Treatment. — Reduction is generally easy, and is effected either by 
traction and coaptation, or, better, by forced flexion of the thumb aided, 
if necessary, by impulsion downward of its base. This latter method is 
analogous to that recommended in the treatment of the dorsal variety, 
but there is not the same urgent reason for it that arises in the latter 
from the relations of the sesamoid bones. If any difficulty should arise 
from the tension of the displaced extensor tendons the phalanx should be 
inclined toward the side on which they lie before making the usual 
manoeuvre. 

Metacarpophalangeal Dislocations of the Fingers. 

The shallow cavity formed by the articular surface of the base of the 
proximal phalanx is deepened by the thick fibro-cartilaginous anterior 
portion of the capsule, which forms, as in the thumb, a stout transverse 
band or apron which accompanies the phalanx in its displacement, and 
may in like manner become interposed between the bones in a backward 
dislocation. The resemblance is still further increased by the occasional 
development of a sesamoid bone in this ligament, especially at the index- 
finger ; its next most frequent appearance is at the little finger. 

Dislocations of the proximal phalanges of the fingers are much less 
frequent, even when taken together, than those of the thumb ; and those 
of the index-finger are more frequent than those of the other three 
fingers. Of 27 cases collected by Polaillon, the dislocation in 18 was 
backward, and in 9 forward; grouped according to the finger and the 
variety, they are as follows : 



390 DISLOCATIONS OF THE THUMB AND FINGEES. 



Table XII. — Dislocations of the Fingers. 
Index finger . . . .15 



10 backward. 
5 forward. 
2 backward. 
2 forward. 
Ring finger. 3 | ^acWd. 



Middle finger 



Little finger 



2 backward. 
1 forward. 



King and little fingers . . . 1 forward. 

Ring and middle fingers . . 1 backward. 

All four fingers, compound . 1 , direction not mentioned. 

Backward dislocatio?is. — The common cause is hyperextension (dorsal 
flexion) of the finger ; in one case it appears to have been direct pressure 
upon the palmar aspect of the phalanx, forcing it directly backward. 
Experiment upon the cadaver and direct observation in compound dislo- 
cations or after arthrotomy in irreducible ones (Lange, 1 Willemer 2 ), show 
that the rupture of the capsule takes place in front along its attachment 
to the metacarpal bone. Willemer thinks, after many experiments upon 
the cadaver, that simple hyperextension is not competent to produce a 
persistent dislocation, but that it must be combined with such rotation of 
the finger as will bring the flexor tendons to the side of the head of the 
metacarpal bone and allow the latter to slip down past them. In the 
case reported by Willemer the dislocation was irreducible by manipula- 
tion, and Konig resorted to arthrotomy, making an incision on the ulnar 
side of the palmar surface of the joint (index finger) ; he found the 
anterior portion of the capsule had been drawn back past the articular 
surface of the phalanx so that it was completely interposed between the 
two bones, and that a sesamoid bone was developed on it. This makes 
the case strictly analogous to the " complex " form of backward disloca- 
tion of the thumb, and corroborates Farabeuf s opinion that the cause of 
the irreducibility in the latter is to be found in the position of the sesa- 
moid bones rather than in the tension of the tendons of the short muscles ; 
probably in this case also the preceding attempts to reduce by manipula- 
tion had caused the interposition. 

In the report of Lange's case the position of the incision is not stated, 
but probably it also was in the palmar surface. " The smallest possible 
cord of the capsule, which was torn from its attachment to the meta- 
carpus, had interposed itself like an apron between the dorsum of the 
metacarpus and the border of the articular plane of the phalanx. 
He was obliged to incise and draw outward the light lateral parts of the 
capsule, when reduction was effected without difficulty. A fair result 
was obtained." 

A similar condition was observed in a case upon which Volkmann 3 
operated in like manner with a good result. 

The symptoms are the prominence of the base of the phalanx on the 
dorsum of the hand, and that of the head of the metacarpal bone in the 

1 Lange: N. Y. Med. Kecord, 1879, p. 100. 

3 Willemer: Centralblatt fur Chirurgie, 1883, p. 566. 

3 Volkmann : reported by Ranke, Berlin, klin. Wochenschrift, 1877, p. 624. 



DISLOCATIONS OF THE MIDDLE PHALANGES. 391 

palm, more or less shortening of the finger, and loss or diminution of 
function. The finger may be extended or slightly flexed upon the meta- 
carpus ; in one case the first phalanx was in rectangular dorsal flexion. 
The middle and distal phalanges are straight or slightly flexed. 

In 5 of Polaillon's 17 cases the dislocation was complicated by a wound 
on the palmar aspect of the joint through which the head of the meta- 
carpal bone projected, and in another the skin was so tightly stretched 
over the end of the bone that it threatened to slough. In 2 cases reduc- 
tion failed (without operation) and in 5 it was difficult, and was at last 
effected by rectangular dorsal flexion of the phalanx and direct impulsion 
downward as in backward dislocation of the thumb. 

Treatment. — If the dislocation is incomplete reduction may be easily 
effected by moderate traction followed by flexion, but in. the complete 
cases it is certainly more prudent to act as in the similar dislocations of the 
thumb in order more surely to avoid the interposition of the anterior 
portion of the capsule. 

Forward dislocations. — The cause, except in an incomplete case 
observed by Malgaigne, has always been notable violence received upon 
the finger, usually in a fall, but the mode of production is not clear. 
Malgaigne' s patient was a shoemaker and caused the dislocation by 
turning in his hand the shoe upon which he was at work. 

The symptoms are the presence of the base of the phalanx in the palm 
and the projection of the head of the metacarpal bone at the back of the 
hand. The finger is extended or slightly flexed, and appears usually to 
be deviated to one or the other side, sometimes very markedly, with dis- 
placement of the extensor tendons toward the same side. Reduction has 
been effected by traction and coaptative pressure. Possibly flexion would 
be efficient in the more difficult cases, as in the similar dislocations of the 
thumb. 

Dislocations of the Middle Phalanges. 

These dislocations may be forward, backward, or lateral. 

Baekivard. — The usual cause is a fall upon the palmar surface of the 
extended finger, which produces the dislocation by hyperextension of the 
phalanx and sometimes ruptures the skin over the front of the joint. The 
phalanx may remain hyperextended upon the proximal one, even to a 
right angle, or may be lowered so that its axis is parallel to that of the 
other. The diagnosis is readily made by examination of the relations of 
the bones, and ordinarily reduction is easily made by direct impulsion of 
the hyperextended phalanx or by traction and flexion. The anterior por- 
tion of the capsule resembles that of the metacarpophalangeal joints in 
being thick and rigid, and it is quite possible, therefore, that it may 
become interposed as above described and make reduction difficult or 
impossible, as in a case treated by Polaillon (loc. cit., p. 184) in which 
all measures failed. It seems advisable, therefore, that the first trial 
should be of direct impulsion upon the hyperextended phalanx, and, this 
failing, the phalanx, still extended, should be pressed bodily toward the 
side on which the flexor tendons may be displaced and then rotated so as 
to carry the tendons forward past the head of the other phalanx. 



392 DISLOCATIONS OF THE THUMB AND FINGERS. 

A special risk associated with the compound dislocations is that of 
tetanus ; in a patient under my care with a compound dislocation of the 
middle and ring fingers the wound had almost entirely healed in about a 
fortnight when tetanus supervened and promptly proved fatal. Some 
compound cases have ended in ankylosis. 

In two reported cases, Langenhagen (quoted by Polaillon) and Pean, 1 
the index, middle, and ring fingers were simultaneously dislocated. 

Forward. — These may be complete or incomplete, according to the 
extent to which the base of the middle phalanx is displaced upward along 
the palmar aspect of the proximal one. The symptoms are the well- 
marked prominence of the head of the first phalanx on the back, and the 
less marked projection of the base of the second phalanx on the palmar 
surface when it is extended. With the displacement upward may be 
associated some lateral displacement or a lateral deviation of the axis of 
the second phalanx. 

Reduction is said to be always easily made by means of traction and 
coaptative pressure, but in an old case treated by Hamilton the effort had 
failed, and in one treated by Thorens the aid of anaesthesia was necessary. 

Lateral. — Of these but few cases have been reported ; Polaillon could 
collect only eight, of which the dislocation was to the inner side in seven, 
and to the outer side in one. In a case quoted by him from Chedan the 
middle phalanges of the last three fingers were simultaneously dislocated 
toward the inner side, forming almost a right angle with the side of the 
first phalanx. Duplay, 2 who saw a case, says "the dislocated phalanx is 
markedly deviated inward so as to form almost a right angle and to cross 
the course of the adjoining finger. At the apex of the angle the lower 
end of the first phalanx can be felt ; the dislocated phalanx projects on its 
inner side." 

In Rollet's case of dislocation to the outer side the base of the second 
phalanx of the ring finger projected upon the outer side of the first 
phalanx ; the second phalanx was somewhat inclined inward, and the 
distal phalanx was slightly flexed. The shortening was about two-thirds 
of a centimetre. 

In two of the eight cases the dislocation was compound, but the 
patients recovered without ankylosis. 

Reduction was easily effected in every case by traction and coaptation. 

Dislocations of the Distal Phalanges. 

These dislocations may be backward, forward, or lateral, the former 
being by far the most frequent ; forward dislocations have, I believe, 
been encountered only in the thumb. 

Backward. — Backward dislocation of the distal phalanx is commonly 
caused by a fall or blow upon the end of the outstretched finger ; it is 
currently thought to be a common accident among ball-players. The 
dislocation may be complete or incomplete, simple or compound, and it 
may be directly backward or backward and to one side. 

1 Pean : France medicale, 1883, vol. 2, No. 23, abstract in Centralblatt fur 
Ohi-ritr'gie, 1883, p. 648. 

2 Djplay : Pathologie Externe, vol. 3, p. 332. 



DISLOCATIONS OF THE DISTAL PHALANGES. 393 

The anterior ligament is torn away from one or the other bone, in the 
thumb usually from the proximal phalanx, in the fingers from the distal 
one. The lateral ligaments remain intact, unless the dislocation is to one 
side as well as backward. The flexor tendon may be torn away from its 
attachment, or it may be displaced to one side. 

Reduction is usually easy, but may be made difficult by interposition 
of the anterior portion of the capsule when this accompanies the distal 
phalanx or by the tension of the displaced tendon. In several compound 
cases of the thumb the obstacle created by the tendon was clearly demon- 
strated and was overcome by drawing the tendon aside with a blunt hook 
or dividing it. 

The phalanx may be hyperextended, or straight, or flexed across the 
end of the proximal one. The coexistence of a wound on the palmar 
surface of the joint is frequent, thirty-two times in fifty-five cases col- 
lected by Polaillon, and has led to very serious consequences, ankylosis, 
gangrene, suppuration extending to the forearm, tetanus. 

Although ordinarily of easy reduction, yet in one-quarter of Polaillon's 
cases reduction failed. As his list is made up largely of reported cases 
it undoubtedly contains an exceptionally large proportion of difficult and 
complicated ones, but still the number of failures, thirteen, is large 
enough to indicate that reduction may often require much care and skill. 
The principles controlling it are the same as in the backward dislocations 
of the other joints, and although simple traction has often sufficed it is 
prudent to refrain from it and to reduce by direct impulsion of the hyper- 
extended phalanx, especially at the thumb. In one case Hamilton 
divided the lateral ligaments subcutaneously. 

Fonvard. — These dislocations have been observed only at the thumb, 
and in a large proportion of the reported cases they have been made 
compound by a wound on the palmar surface. The cause, in the few 
reported cases, has been a blow upon the end of the phalanx by which it 
was forcibly hyperextended. In some cases the phalanx remained in 
this position, its dorsal surface resting against the articular face of the 
proximal phalanx, and its base projecting on the palmar surface ; in other 
cases the phalanx was slightly flexed, and its base displaced upward along 
the anterior surface of the proximal one. 

Reduction has usually been easy by traction or direct pressure. 

Lateral. — These dislocations, of which only four or five have been 
reported, have been caused by falls, by a kick, and by violently shaking 
the hand while grasping it by the end of the finger. The phalanx may 
preserve its parallelism with the other, being simply displaced upward 
along its side, or it may form a lateral angle with it, its base resting 
against the side of the other. In Gogue's case, quoted by Malgaigne, 
there was a transverse wound fifteen millimetres long through which the 
head of the middle phalanx protruded. In Duges's, case reduction was 
not attempted ; in the others it was easy. 



CHAPTEE XXIV. 

DISLOCATION OF THE PELVIS. DISLOCATIONS OF THE COCCYX. 

The union of the two innominate bones at the symphysis pubis is by 
a solid fibrocartilaginous band, and without an articular cavity, and the 
rupture of this band, or its separation from one or the other bone, belongs 
more properly among fractures than among dislocations. Between the 
auricular surfaces of the ilium and sacrum there is usually an articular 
cavity, but it is often more or less obliterated by fibrous union between 
the opposed cartilaginous surfaces. Pure separations at these points 
without fracture are rare, and, except at the pubic symphysis, hardly to 
be diagnosticated with certainty during life. The reader is, therefore, 
referred for most that pertains to the subject to the chapter upon fractures 
of the pelvis. 

Malgaigne described the lesions as dislocations, and most writers have 
followed his example. His classification is as follows : 

Dislocations of the pubic symphysis. 

Dislocations of the sacro-iliac symphysis. 

Dislocations of these two symphyses, or of the ilium. 

Dislocations of the two sacro-iliac symphyses, or of the sacrum. 

Dislocations of the three symphyses, or of the three bones simultane- 
ously. 

Dislocations of the coccyx. 

Of these, only the last is, strictly speaking, to be deemed a dislocation. 

Two cases that have been recently reported deserve mention, as addi- 
tions to the statistics of the injury. In one, 1 a man twenty-one years old, 
fell, and was struck upon the back by a heavy piece of timber ; a fracture 
of the thigh w T as recognized, and, in addition, a peculiar prominence of 
the right hip, the nature of which was not at the time determined, 
although nothing abnormal in the hip-joint could be recognized. Two 
and a half weeks later the right os innominatum was found somewhat 
depressed, and separated one and a half inches laterally from the sacrum. 
Although the patient fell and broke the thigh twice again, four and six 
months after the first injury, he recovered sufficiently to walk with the 
help of a cane, and do light work. The union between the ilium and 
sacrum was firm, but some displacement persisted. 

In the other case, 2 a man twenty years old fell while aiding to carry a 
heavy piece of timber, and was caught under it. On the following day 
an examination was made under chloroform, and the right ilium was found 
to have separated from the sacrum, and to project markedly backward, 
but the pubic symphysis was unchanged. The next morning the right 

1 Groner : Annals of Surgery, 1885, vol. 1, p. 463. 

2 Varrailhon : Kevue de Chirurgie, 1886, p. 821. 



DISLOCATIONS OF THE COCCYX. 395 

pubis was found to project forward and upward at the symphysis, about 
a centimetre, although the patient had not changed his position, and the 
pelvis had been supported by a broad bandage. The patient recovered 
entirely, without deformity in three months. 

Dislocations of the Coccyx. 

The systematic descriptions of dislocations of the coccyx which are 
given by the earlier writers were called in question by those of the first 
half of the present century, some of whom, especially Boyer, went so far 
as to deny that the lesion had ever occurred. Malgaigne, however, 
collected six cases of dislocation forward, and described a backward form 
on the authority of Lauverjat. To these six maybe added four that have 
been since reported, Roeser, 1 Bonnefont, 2 two cases, and Mouret, 3 the 
first of which is an example of a variety, lateral dislocation, that has not 
heretofore been described. It must further be said that many cases have 
been encountered and reported in which a group of symptoms identical 
with those observed in cases reported as dislocations, and following similar 
accidents, falls, blows upon the anal region, has been presented, and the 
conclusion seems to be unavoidable, either that dislocations or fractures 
of the coccyx are much more frequent than the number of reported cases 
indicates, or that the prominent symptoms which accompany the recog- 
nized cases, the excessive pain, disability, and general nervous disturbance, 
are due to something else than the displacement of the bone. Against 
the latter alternative may be urged the immediate relief and prompt 
recovery which have followed the reduction of the displacement. Six 
cases in which the general symptoms were similar to those of dislocation, 
but in which no displacement was recognizable, are reported by Warren, 4 
and Mouret's case may perhaps be classed with them. 

Of eight of the above cases in which the sex is noted, six were women, 
and two men ; all were adults; and the obscure injury just referred to, 
in which the symptoms are the same, except that no displacement is recog- 
nizable, is also much more frequent in women than in men. 

Dislocations forward. — The usual cause is violence received upon the 
region of the coccyx in a fall upon the buttocks or astride a bar, or by 
the breaking of a chamber upon which the patient was sitting. The two 
men, Ravaton, Mouret, were injured while on horseback, one of them 
suddenly in jumping a ditch, the other without special cause or incident, 
the pain coming on gradually, and increasing for twenty-four hours, and 
then suddenly becoming very severe after a slight change of position, with 
a sensation of something slipping in the rectum. 

The pain at the moment of the accident is so severe as sometimes to 
cause the patient to faint ; there is pain in defecation, and frequent calls 
to urinate. The pain radiates down the thighs, and sometimes over the 
trunk, head, and arms ; the patient is unable to sit up, and the slightest 

1 Koeser : Froriep's Notizen, 1857, vol. 2, No. 10. Abstract in Brit, and For. Med. 
Chir. Fvev., 1857, vol. 20, p. 414. 

2 Bonnefont : Union Medicale, 1859, i. p. 136. 

3 Mouret: Eed. de Mem. de Med. Chir. et Fharm. militaires, 1859, i. p. 350. 

4 Warren: Surg. Observations, Boston, 1867, p. 593. 



396 DISLOCATIONS OP THE COCCYX. 

movement may greatly increase the suffering. Coughing and sneezing, 
and sometimes even every act of inspiration increase the local pain. If 
the condition remains unrelieved (Turner, a week ; Ravaton, seventeen 
days ; Bonnefont, a month) the general health suffers seriously, the patient 
becomes feverish,- and the mind dulled. 

External examination may show an ecchymosis and swelling over the 
situation of the coccyx and a displacement of this bone forward ; the 
finger introduced into the rectum recognizes an angular displacement of 
the coccyx, in which its point is directed forward, and which is sometimes 
so great that the bone stands almost at right angles to its normal position, 
and presses the posterior wall of the rectum sharply forward. 

If now the finger is hooked over the projecting end of the coccyx it 
can be readily drawn back into place, and the reduction is followed by 
immediate, instantaneous relief of all the symptoms. A marked tendency 
to recurrence usually exists and may make it necessary to repeat the 
reduction several times. In one of Bonnefont's cases a gum catheter 
with a stylet was bent into the shape of a hook and so placed in the anus 
that by traction upon the projecting portion the bone could be kept in 
place. In Turner's case the cure was less complete ; the coccyx pre- 
served an abnormal mobility for many years, and the patient was obliged 
to facilitate defecation by introducing her finger into the anus. 

Dislocation backward is lightly mentioned by some writers as a not 
infrequent accident during parturition. Malgaigne quoted Lowenjat as 
follows : " The considerable deviation backward of this bone sometimes 
causes its dislocation. I have seen one case. The patient suffered aston- 
ishingly, and could not sit ; I reduced the coccyx and she was immediately 
cured." 

Lateral dislocation. — Of this only one case, Roeser, has been reported. 
The patient, a large, corpulent woman, thirty-six years old, fell astride 
the back of a chair. She at once suffered severe pain in the coccygeal 
region, much aggravated by attempts to sit, but she was able to go about 
for some hours. At last the pain became so severe that she took to her 
bed, when she found she could neither move nor turn. When seen the 
next day there was so much immobility and stiffness of the body as to 
suggest tetanus. Besides the severe pain in the coccygeal region she com- 
plained of a painful, tense, dragging sensation, extending up toward the 
nape, and along the arms to the fingers which felt numb. She could not 
bear to make the slightest movement. The head was confused, and the 
intellect somewhat clouded. No unnatural sensation in the lower limbs ; 
urine and feces were passed naturally. 

A small swelling was felt on the left side of the fissure of the buttocks, 
which proved to be the coccyx torn away from the sacrum, and carried 
toward the left ischium. The end of the scrotum from which it had been 
displaced could be plainly felt. The finger in the rectum showed the exact 
nature of the displacement still better, and when firm pressure was made 
downward and to the right against the displaced bone, it suddenly re- 
sumed its normal position. The patient declared she immediately felt 
quite another being, the confusion of the head and painful sensation 
along the spine and anus disappearing. At the end of the fifth day no 
inconvenience beyond a slight burning pain near the sacrum remained. 



CHAPTEE XXV. 

DISLOCATIONS OF THE HIP. 
ANATOMY. STATISTICS. CLASSIFICATION. BACKWARD DISLOCATIONS. 

Anatomy. — The bony constituents of the hip-joint are the acetabulum, 
or cotyloid cavity of the os innominatum, and the globular head of the 
femur. The former is an almost hemispherical cavity, situated at the 
junction of the ilium, ischium, and pubis, and formed by the projection 
from their outer surface of a strong bony rim, which is especially thick 
and prominent behind and above, and is lacking below for nearly an inch 
at the point where the cavity adjoins the foramen ovale, the cotyloid 
notch. The posterior, upper, and anterior portions of the cavity are 
lined by articular cartilage, but the centre of the cavity and the portion 
between it and the cotyloid notch are uncovered by cartilage, and are 
occupied by fat, and, at the lower part, by the ligamentum teres. The 
depth of the cavity is increased by a fibro-cartilaginous rim set upon its 
edge, the labrum cartilagineum, or cotyloid ligament, which crosses the 
cotyloid notch, and is there termed the transverse ligament. The centre 
of the cavity lies in a line drawn from the anterior superior spine of the 
ilium to the lowest or most anterior part of the tuberosity of the ischium. 
The wall of the cavity is thin at its centre and lower part, and is else- 
where very thick and strong. Its growth takes place at the junction of 
the three bones which combine to form it, this junction being marked 
during the period of growth by a thin layer of conjugal cartilage having 
the shape of an inverted Y. 

The head of the femur is rather more than half of a sphere, having a 
radius of about an inch, and is so placed upon the neck that rather more 
than half of its cartilage-covered surface is in front and above (in the 
upright position), and rather less than half is behind and below. At a 
point a little below that at which a prolongation of the long axis of the 
neck would touch its surface is a depression, within which the upper end 
of the ligamentum teres is attached. 

The curves of the head and the cotyloid cavity are almost, if not 
entirely, identical ; the small gaps that are sometimes found between 
them are probably due to irregularities in one or the other surface, 
although they are attributed by some anatomists to normal departures 
from the exactly spherical form, or to slight differences in the length of 
the radii of the two surfaces. 

The neck is directed inward, upward, and slightly backward from its 
junction with the shaft, the angle which it makes with the long axis of 
the latter being about 130°. The great trochanter, continuous with the 
outer surface of the shaft, overlaps the neck above and behind, its highest 
part being situated posteriorly and curved inward ; the portion which is 



898 



DISLOCATIONS OF THE HIP. 



most external and most nearly subcutaneous is about an inch below the 
upper margin. To this trochanter and to the digital fossa which adjoins 
it on the inner side above and behind pass all the outer and posterior 
muscles, except the gluteus maximus and quadratus femoris, which come 
from the hip-bone. The small trochanter is a rounded prominence upon 
the inner and posterior aspect of the shaft close below its junction with 
the neck, and gives attachment to the psoas-iliacus muscle. 

The capsule is attached above along the entire periphery of the coty- 
loid cavity, just outside the free margin of the labrum cartilagineum, and 
below to the femur at or near the junction of the neck and shaft, extending 

in front to the inter-trochanteric 
FlG - 118 - line, above nearly to the root of 

the great trochanter in the digital 
fossa, behind to the neck itself a 
little short of its outer limit, and 
below to the upper part of the 
lesser trochanter. It is composed 
of fibres arranged longitudinally 
and circularly, and varies greatly 
in strength and thickness at dif- 
ferent points. Those portions 
which are especially thickened by 
multiplication of the longitudinal 
fibres are known as accessory 
ligaments ; of these the strongest 
and most important is the one 
situated in the anterior part of 
the capsule, and known as the 
ilio-femoral ligament, or the liga- 
ment of Bertin, or Bigelow's 
Y-ligament (Fig. 118). This 
arises from the anterior inferior 
spine of the ilium, and from the 
surface of the bone immediately 
behind it and above the edge of 
the acetabulum, and its fibres 
passing downward diverge to form 
two strong bands, of which the 
inner passes almost vertically to 
the lower part of the anterior intertrochanteric line, and the outer to the 
upper part of the same line. The ligament is about one-fourth of an inch 
thick at its thickest part, and is very strong, perhaps the strongest in the 
body, and will sustain without rupture a strain of from 250 to 750 pounds 
(Bigelow). Its inner portion is especially concerned in limiting extension 
of the limb ; its outer portion in limiting eversion. 

The other thickened portions of the capsule are those known as the 
pubo-femoral and ischio-femoral ligaments ; the former arises from the 
anterior and inferior portion of the acetabular margin and the pubis as 
far inward as the pectineal eminence, and extends in the anterior and 
lower part of the capsule to its insertion above the small trochanter. The 




The ilio-femoral, or Y-ligament. (Bigelow.) 



DISLOCATIONS OF THE HIP. 399 

ischiofemoral ligament is a strong band of fibres on the outer and poste- 
rior portion of the capsule, arising from the groove on the ischium below 
the acetabulum. The pubo-femoral ligament limits abduction ; the ischio- 
femoral limits inversion. On each side of the pubo-femoral band the 
capsule is very thin, and through these thin portions the head of the 
femur passes in the pubic and obturator dislocations ; outside and behind 
the Y-ligament, where some of the dorsal dislocations occur, the capsule 
is very strong, limiting adduction and inward rotation (Bigelow). 

The ligamentum teres is a triangular band attached by its base to the 
transverse ligament and the adjoining central portion of the acetabulum, 
and by its apex to the depression on the inner surface of the head of the 
femur. It is not strong and probably is without important influence in 
limiting the movements of the femur ; its chief function appears to be 
to convey bloodvessels to the head of the femur. 

The cavity of the joint usually communicates through an opening in 
its anterior portion with a bursa under the tendon of the ilio-psoas muscle. 

Fig. 119. 




Eelations of the head of the femur and the obturator internus. (Bigelow.) 

The joint is thickly covered in by muscles, of which it is desirable 
here to mention only one, the obturator internus, which plays an impor- 
tant part in the backward dislocations. This muscle, arising from the 
inner surface of the obturator foramen and the surface of bone between 
it and the great sacro-sciatic notch, passes outward through the small 
sacro-sciatic notch, turns sharply forward, and is inserted upon the front 
part of the inner surface of the great trochanter in conjunction with the 
two gemelli which arise respectively from the spine and tuberosity of the 
ischium. Bigelow found it to be the strongest of the external rotators, 



400 DISLOCATIONS OF THE HIP. 

rupturing under a strain of forty and four-fifths pounds, 1 and this greater 
strength he attributed to the mingling with its muscular belly of tendinous 
fibres, some of which extend to a bony attachment within the pelvis and 
thus become actual restraining ligaments when the muscle is fully 
extended. Its action is to evert the extended, to abduct the partly flexed 
thigh. Above it is the pyriformis, below it the quadratus femoris. 

The centre of the head of the femur lies about two inches directly 
below the anterior inferior spine of the ilium, and at about the same 
distance downward and outward from the centre of, and in a direction at 
right angles to, a line drawn from the anterior superior spine of the 
ilium to the spine of the pubis. When the bones are normal and in 
place, and the limb is partly flexed, a line drawn across the outer aspect 
of the thigh from the anterior superior spine of the ilium to the lowest 
part of the tuberosity of the ischium will cross the upper part of the 
great trochanter. This is knoAvn as Nelaton's, or the Nelaton-Roser, 
line ; its relations to the trochanter have great diagnostic importance. 
In the child, according to Hueter, the trochanter is brought somewhat 
higher by the relative shortness of the neck of the femur. 

The range of motion of the joint has been very carefully studied by 
Albert ; 2 he found that in a preparation consisting of only the bones and 
ligaments the range of flexion and extension was 140°, and that of abduc- 
tion and adduction 90° to 100°, of which abduction (from the sagittal plane) 
was 60°, and adduction 30° or 40°. If the muscles were left in place 
flexion was diminished 30°, and adduction reduced to 20°. In other words, 
extension and abduction are checked in the living by the ligaments of 
the joint, flexion and adduction by the muscles or by the contact of the 
limb with the abdomen in flexion. The range of abduction and adduc- 
tion is further modified by the position of the limb as regards its flexion 
and its rotation about the long axis. 

The position of the limb in which dislocation of the hip most frequently 
occurs is that of flexion, adduction, and inward rotation, and the dislo- 
cation which then occurs is usually one of the backward forms, although 
after the head of the bone has left the socket abduction and outward 
rotation of the limb may lodge it in the obturator foramen. In this 
position the posterior and inferior portion of the capsule is put upon the 
stretch and ruptured. By outward rotation and abduction the head may 
be forced out at the lower and inner part of the capsule below the pubo- 
femoral ligament, toward the obturator foramen ; in each case a new 
centre is found for the exaggerated movement in the more or less direct 
contact between the neck of the femur, and the margin of the acetabulum 
or in the tension of part of the Y-ligament. The force which produces 
the dislocation, therefore, almost always acts indirectly, either by moving 
the limb upon the fixed trunk or by moving the trunk upon the fixed 
limb. In the great majority of cases the Y-ligament remains untorn, 
and by the restraint which it exerts upon the movements of the displaced 
femur it determines in a large measure the character of the secondary 
displacement, the attitude in which the limb comes to rest, and the mani- 
pulations by which the dislocation can be reduced. This influence is so 

1 Bigelow: The Hip, 18G9, p. 22. 2 Albert: Chirurgie, vol. 4, p. 248. 



DISLOCATIONS OF THE HIP. 401 

great that Bigelow based upon it the distinction which he made between 
" regular '' and " irregular " dislocations, the former including those cases 
in which the ligament remained untorn and the attitude of the limb was 
in consequence characteristic ; the latter those in which the ligament was 
more or less torn and the attitude and displacement variable. The 
distinction has sometimes an important bearing upon the treatment and 
deserves to be preserved. 

Statistics. — The tables in Chapter I. show that the percentages of 
dislocation of the hip, compared with all dislocations, vary from 2 per 
cent. (Kronlein) to 9.76 per cent. (Prahl) and that the percentages in the 
combined hospital and polyclinic 1432 cases is the same, 8.8 per cent., 
as in the 964 hospital cases. Agnew 1 says that of 912 dislocations 
admitted to the Pennsylvania Hospital 89 (9.75 per cent.) were of the 
hip. Of Kronlein's 8 cases 4 were in patients not more than ten years 
old, and of Prahl's 41 cases 12 were of the same age, 8 were between 
eleven and twenty, and 11 were between twenty-one and thirty years old. 
This preponderance in youth is, however, not found in Agnew 's list or 
in the 41 cases collected by Malgaigne or the 84 cases collected by 
Hamilton. The latter were divided as follows : 



Under 15 years . . 15 
15 to 30 " . 32 

30 " 45 " . 29 


45 to 60 years 
60 " 85 " 


. 7 
. 1 


new's 89 cases are thus divided : 






15 to 25 years . . 39 
25 " 30 " . 26 
35 " 45 " . 12 


45 to 55 years 
55 " 65 " 
65 " 75 " 


. 6 
. 5 
. 1 



Although the numbers are larger in Hamilton's collection than in 
Prahl's, yet, as the latter are the integral statistics of a single hospital 
and dispensary, I think its percentages are more likely to represent the 
actual proportions than those of a collection of published cases are. It 
is true that the general impression of the profession is that the injury is 
especially frequent in early middle life, but this impression may have 
been created by Malgaigne's and Hamilton's statistics. I do not know 
how to account for the absence from Agnew's list of patients under 
fifteen years of age. 

The earliest age at which a dislocation has been reported is six months 
(Powdrell, Lancet, 1868, i. p. 617), it was a dislocation upon the obtu- 
rator foramen, and was caused by the fall of a chair in which the child 
was tied. In the report by W. A. Johnson, 2 of a clinical lecture by 
Prof. Gross, it is said, "upward of six years ago this child, M. S., aged 
seven years, had a fall," and received a dorsal dislocation of the hip. 
The note is entitled " Dislocation of the hip-joint in a child six months 
of age." Bartels 3 reported a dorsal dislocation at eleven months caused 
by the effort made to put on a shoe. Several others have been reported 
between the ages of eighteen months and five years. 

1 Agnew : Surgery, vol. 2, p. 89. 

2 Johnson : Phil. Med. Times, 1876-7, vol. 7, p. 5. 

3 Bartels: Arch, fur klin. Chir., 1874, vol. 16, p. 650. 

26 



402 DISLOCATIONS OF THE HIP. 

The oldest patient is one reported by Kennedy, 1 a woman, aged ninety- 
one years and five months, who received a dorsal dislocation of the right 
hip by a fall, while walking across a smooth floor ; it was reduced on the 
twelfth day by manipulation, and two days later the patient died. The 
autopsy verified the diagnosis. The next oldest patient, eighty-six years, 
was also a woman (Gauthier, quoted by Malgaigne, loc. cit., p. 805); 
and the next, a man eighty-one years old, whose dislocation was supra- 
pubic and was verified by autopsy four years later, the neck of the bone 
was broken by an attempt to reduce while the injury was recent ; the case 
Avas reported by Verneuil. 2 Agnew says he found in the records of the 
Pennsylvania Hospital five cases between the ages of seventy-five and 
eighty-five years. They do not appear in the tabulation above quoted. 

The injury is much more common in males than in females: of 
Agnew's 89, 11 were women ; of 115 cases collected by Hamilton, 104 
were males. 

Concerning the relative frequency of the different varieties it can be 
said that those in which the head of the femur is found resting upon the 
lower part of the ilium behind the outer posterior half of the acetabulum, 
the so-called " iliac" dislocation, to preserve for the moment the old clas- 
sification, or still lower down on the upper part of the ischium, " ischiatic" 
dislocations, are much more frequent than those in which it rests in 
front or on the inner side of the acetabulum, the suprapubic and obturator 
dislocations. The dislocations upon the dorsum of the ilium are generally 
thought, on clinical evidence, to be more frequent than the ischiatic, but 
a comparison of the cases examined after death does not corroborate this 
view ; Malgaigne collected 10 autopsies of ischiatic dislocations, and only 
6 of the iliac, one of these being primarily ischiatic, and Lossen, 3 taking 
only cases reported since 1855, found 19 ischiatic, and only 5 iliac. 
Probably Malgaigne's supposition is correct that many ischiatic cases 
observed clinically are thought to be iliac ; indeed, it will further appear 
that in many "iliac " dislocations the head of the femur has primarily 
passed downward and backward, and that its presence upon the dorsum 
of the ilium is due to a secondary displacement upward. Roser goes so 
far as to claim that the iliac dislocations, in which the head of the femur 
has left the cotyloid cavity by its upper posterior portion, are the rarest 
of all the principal forms. Of the two anterior forms the obturator seems 
to be more frequent than the suprapubic, but the reported cases are too 
few to justify a positive assertion. 

Simultaneous dislocation of both hips has been reported in several 
cases. Two of them, Boisnot and Schinzinger, have been quoted in 
Chapter I. ; Malgaigne quotes two, and Gibson, Crawford, Steiner, 
Roberts, James, Jung, Wood, Pollard, Bigelow, Fischer, Kunschert, 
Barker, Pri chard, Allis, Packard, and Bourrienne have each 'reported one. 

Compound dislocations are very rare, as might be expected from the 
thickness of the soft parts, which everywhere cover in the joint. The 

1 Kennedy: Cincin. Lancet and Clinic, 1878, i. p. 256. 

2 Verneuil : Bull, de la Soc. de Chir., 1865, vol. 6, p. 495. 

3 Lossen : Deutsche Chirurgie, Lief. 65, p. 30. 



DISLOCATIONS OF THE HIP. 403 

recorded cases are those of Walker, 1 Bransby Cooper, 2 Macouchy,* 
Moxon, 4 a German military surgeon, 5 Taylor, 6 and Woodward. 7 . The 
first and fifth have been quoted in Chapter III., p. 39. The second is 
not spoken of by Cooper as a compound dislocation, but the history indi- 
cates that it probably was one ; the patient, a lad seventeen years old, 
was run over by a wagon, the wheel passing across the back of his thigh 
and producing a dislocation forward and inward, the head of the femur 
lying to the inner side of the great vessels. A rather large lacerated 
wound was situated just below Poupart's ligament, a little to the inner 
side of its centre. Profuse suppuration followed, and the patient died on 
the twentieth day. 

Macouchy's patient was a boy fourteen years old, who fell from a mast 
to the deck, a distance of sixty feet, and received, in addition to the dislo- 
cation, a fracture of the base of the skull. When seen, he was sitting 
on the deck with the head of the femur appearing between his legs, 
through his pilot-cloth trousers, as if protruded from his anus. The head, 
neck, and great trochanter protruded through the integuments covering 
the posterior third of the ischium, the head of the bone resting on the 
posterior part of the tuberosity of the ischium of the opposite side. The 
head was sawn off, and the shaft replaced. The patient died two days 
later. 

Moxon's patient, a railway porter, was injured by a moving train and 
died shortly afterward in Guy's Hospital. The position of the limb was 
that of dislocation on the dorsum ilii. There was a large irregular rent 
in the skin corresponding to the junction of the left sacro-sciatic liga- 
ment with the tuber ischii. On passing three or four fingers into the 
hole a way was found through a pulp of torn muscles and bloodclot, till 
the fingers rested on the naked head of the thigh bone. The gluteal 
muscles were much torn up and infiltrated with blood. The head of the 
thigh bone lay half an inch outside the great sciatic nerve, free under 
the remains of the glutei. It had escaped through the muscles imme- 
diately around the joint by passing between the quadratus femoris and 
obturator internus. A portion of the head of the bone remained in the 
socket, attached by the round ligament. 

Taylor's patient was a lad seventeen years old who was overthrown by 
a falling tree and received a dislocation into the obturator foramen 
together with an irregular wound nearly two inches long in the perineum 
through which the head of the femur could be distinctly felt. Most of 
the muscles had been separated from the descending ramus of the pubis 
and the ascending ramus of the ischium. Reduction was made with some 
difficulty, and the limb immobilized on a long side splint. The wound 
healed promptly, and at the end of nine weeks the splint was removed, 
but on the next day inflammatory symptoms appeared on the side of the 
hip, and an abscess formed and was opened. Eight months later Taylor 
met the patient riding on horseback. 

1 Walker, quoted by Cooper: Loc. cit. , p. 80. 2 Cooper: Loc. cit., p. 76. 

3 Macouchy : Dublin Hosp. G-az., 1872, i. p. 21. 

4 Moxon : Med. Times and Gaz., 1872, i. p. 96. 

5 Centralblatt fur Chir., 1880, p. 504. 6 Tavlor : Lancet, 1881, i. p. 732. 
7 Woodward: Boston Med. and Surg. Journ., 1883, vol. 108, p. 129. 



404 DISLOCATIONS OF THE HIP. 

Woodward's patient, a boy twelve years old, was caught under a 
freight car and rolled over and over, receiving several fractures in addi- 
tion to the dislocation. The wound was a longitudinal slit about two 
inches long on the inner side of the thigh two and a half inches below the 
angle of the pubes. The limb was abducted, making an angle of nearly 
45° with the line of the body, and the foot was everted. The head of the 
femur, together with the great trochanter entirely stripped of its muscles, 
projected completely through the opening for about four inches and lay 
across the scrotum. Its point of exit was just anterior to the adductor 
longus. No fracture of the femur or pelvis was detected, and the great 
vessels were uninjured. The patient died in five hours, and after death 
reduction could not be made. 

Classification. — The classifications adopted by the earlier writers were 
necessarily faulty and deficient because of the lack of recorded experience 
and post-mortem examinations. That of Hippocrates, containing four 
principal forms, outward, inward, forward, and backward, was employed,, 
according to Malgaigne, until the seventeenth or eighteenth century, 
although the terms do not seem always to have been applied in the same 
sense. Petit, in the eighteenth century, made two main groups, inward and 
outward, each with two subdivisions, the four being upward and inward, 
downward and inward, upward and outward, and downward and outward, 
but he thought it impossible that the latter form could occur. Verduc, 
about the same time or a little earlier, sought to substitute a classification 
based upon the place at which the head of the femur came to rest, and in 
this he was supported by Duverney and Bertrandi, and thus arose the 
terms dislocation upon the ilium, upon the ischium, upon the pubes, into 
the foramen ovale. Sir Astley Cooper gave us dislocations upward, or 
on the dorsum ilii, downward, or into the foramen ovale, backward, or 
into the ischiatic notch, and dislocation on the pubes ; and Gerdy followed 
with supra-pubic, sub-pubic, iliac, sacro-sciatic, and ischiatic, the latter 
being directly downward. 

Malgaigne was the first to bring to the subject the results of careful 
study of many pathological specimens ; he showed that in the backward 
dislocations the head of the femur did not go so far as the anatomical 
terms used in Cooper's classification, for example, would indicate, but 
that on the contrary it usually remained so near the cotyloid cavity that 
it partly overlapped it, "incomplete" dislocations, as he called them, and 
he proposed a classification in four groups, of which the first two were 
the same as Petit's, though the names are different, as follows : 

Dislocations backward I iliaC ' com P lete > incomplete, 
dislocations backward j i schiatic? com p] ete , incomplete. 

Dislocations forward { J^p^ic. 
Dislocations upward supra-cotyloid. 

Dislocation downward {£*£ffi 

The names ilio-pubic and ischio-pubic were taken from those of corre- 
sponding depressions on the margin of the cotyloid cavity along which, 
the head of the femur was thought to pass, and, acting on the same plan,, 



DISLOCATIONS OF THE HIP. 405 

Nelaton gave the name ilio-ischiatic to all the backward dislocations, 
which Malgaigne preferred to divide into two groups. 

In Germany Roser and Busch adhered to the method of classification 
according to the direction taken by the head of the femur, Roser making : 

Dislocations outward and backward (outer posterior margin of the acetabulum). 
Dislocations downward and backward (between the spine and tuberosity of the 

ischium). 
Dislocations forward and upward (anterior margin of the pelvis). 
Dislocations inward and downward (toward the foramen ovale). 

and Busch : 

tv -, , . f A f forward and upward. 

•Dislocations forward . . j forward Rnd d £ wnwarcL 

tv "i ' A* -U i j f backward and upward. 

Dislocations backward . . j backward and downward . 

Of the latter German writers Albert makes three groups : backward, 
forward and upward, and forward and downward ; Konig and Lossen 
make four, as follows : 



| iliac. 
{ ischiatic. 

supra-pubic ■ J g^p^ctmeal. 



Backward 



F <™' d . , . . oMu' Iter 

mfra-pub.c [ perJneal _ 

Supra-cotyloid. 
Infra-cotyloid. 

In England Sir Astley Cooper's classification has been more or less 
completely retained, although some surgeons (Erichsen) place the back- 
ward dislocations, those " upon the dorsum ilii " and " into the sciatic 
notch," in one group and call them " dislocations backward and upward." 

In America Hamilton used Cooper's classification ; and Agnew does 
the same, although he groups the iliac and ischiatic together as varieties 
of a single form " upward and backward." 

Bigelow, 1 to whose researches and writings so much of the recent 
advance in the knowledge of the subject and in the treatment of the 
injury is due, made a classification of seven regular and principal forms, 
which he based not merely upon the direction in which the bone had been 
dislocated or the point at which it came to rest, but also upon the integ- 
rity of the Y-ligament or the rupture of its outer branch, and the changes 
in the attitude of the limb which arise from such rupture. Such a classi- 
fication was open to the objection that it gave equal rank to forms which 
were only variations of others, and a few years later he modified it 2 by 
grouping all under four heads and by suppressing the distinction between 
the " dorsal" and the " dorsal below the tendon," which latter name he 
had previously given to the lower of the two dorsal varieties, the " dislo- 
cation into the sciatic notch" of Cooper. His new classification, then, 
was the following : 

External to the socket ; comprising the dorsal and the dorsal with 
eversion. 

1 Bigelow : The Hip. 2 Bisjelow : Lancet, 1878, 1, p. 894. 



406 DISLOCATIONS OF THE HIP. 

Internal to the socket ; on the perineum, the thyroid foramen, and the 
pubes. 

Below the socket ; dislocation toward the tuberosity of the ischium. 

Above the socket ; the subspinous, the supraspinous, and the anterior 
oblique. 

This also was open to the serious objection that varieties which were 
alike in their mode of production, in the point at which the head of the 
femur left the socket, in the direction it afterward took, and in treatment 
were placed in different main divisions, and Professor Bigelow, therefore, 
went further and presented in the same paper the following classification 
which he recommended as a sufficient " practical grouping." 

Dorsal, comprising the dislocation on the tuberosity of the ischium, 
the dorsal, the everted dorsal, the anterior oblique, and the supraspinous. 

Thyroid, comprising that in the perineum and that on the thyroid 
foramen. 

Pubic, comprising the pubic and the subspinous. 

Turning now to the results of the examination of specimens and of 
experiments upon the cadaver, it appears that in the more frequent forms 
the head of the femur passes over the outer, posterior, margin of the 
cotyloid cavity, usually at or below its horizontal diameter, while the 
limb is flexed, adducted, and rotated inward ; then by the sinking of the 
knee the femur turns upon its attachment to the Y-ligament as a centre, 
and the head rises to a higher level along the outer surface of the acetab- 
ulum or further backward on the flat surface of the ilium in front of, 
and seldom higher than, the apex of the great sciatic notch. It is to be 
borne in mind that this apex is not very much above the level of the 
highest part of the cotyloid margin. In this movement the head of the 
femur frequently passes behind the untorn tendon of the obturator 
internus, leaving that tendon between itself and the acetabulum. Or, if 
it crosses the margin of the cotyloid cavity at or above its horizontal 
diameter it may tear the obturator internus and pyriformis or pass 
between these muscles and come to rest at the same point as before. The 
former is the dislocation "below the tendon," the latter the "dorsal " 
or the dislocation " upon the dorsum ilii," as these terms were origin- 
ally used, but the distinction appears to be one which cannot often 
be made clinically. The important difference between them is in the 
situation of the rent in the capsule, which is higher in the latter than in 
the former and will probably permit redaction by traction downward. 

Exceptionally, if, after the dislocation has occurred, the knee is still 
further lowered and the limb abducted and rotated outward, the outer 
branch of the Y-ligament ruptures and the head of the femur passes 
forward along the ilium toward its anterior inferior spine or the interval 
between the two spines, the " everted dorsal" of Bigelow, the "supra- 
spinous " or part of the " supra-cotyloid " of others. The attitude of 
the limb in this is very different from that of the common backward 
dislocation of which this is a variety by secondary displacement. 

But the head of the femur may not only come to rest directly above 
the cotyloid cavity by a secondary displacement forward and inward ; it 
may also reach nearly the same point by a secondary displacement out- 
ward and backward from a primary dislocation forward upon the pubis. 



DISLOCATIONS OF THE HIP. 



407 



The distinction between the two is radical, for in the former the root of 
the Y-ligament lies on the inner side of the head, which must be returned 
to its socket by passing backward behind the acetabulum ; and in the 
latter the Y-ligament lies to its outer side and the head must be returned 
along the front or inner side of the acetabulum. There is still a third 
way in which the head may be placed above the acetabulum, although at 
a somewhat lower level, and that is by direct displacement upward, with 
rupture of the upper part of the capsule and of the Y-ligament, but this 
is extremely rare, and the cases belong among the ' ; irregular " dislo- 
cations. 

The dislocations forward (or inward) and upward and inward and down- 
ward offer no difficulties in classification ; each has its characteristic 
symptoms, although the perineal variety of the latter is somewhat sharply 
distinguished from the obturator or thyroid variety by the flexion, almost 
at a right angle, of the limb. Bigelow thinks the supra- pubic can be 
produced by a secondary displacement upward after the head has escaped 
at the lower part of the capsule during flexion of the limb, in a similar 
manner and by the same mechanism (lowering of the knee) as a secondary 
"iliac" dislocation is produced from a primary " ischiatic " one. In 
short, he thinks (Lancet, 1878) that in most cases the head of the femur 
escapes over the lower margin of the acetabulum and then passes upward 
as the limb is lowered, and either behind or in front of the acetabulum 
according as the limb is adducted or abducted, and upon this theory he 
bases a simple rule of treatment applicable to both anterior and posterior 
dislocations, namely, flex the limb at a right angle to bring the head 
below the socket, and then lift it into place. 

Finally, the head may be displaced downward upon the adjoining 
branch of the ischium, and rest there (subcotyloid) ; the position is one 
from which the head can be easily dis- 
placed, either backward or forward, and 
the dislocation thereby transformed into 
a dorsal or obturator one. 

The distinction between the two back- 
ward forms, upon the dorsum ilii and 
toward the sciatic notch, which has 
already been abandoned by eminent 
surgeons (Bigelow, Erichsen, Albert), 
does not appear to deserve to be retained, 
except, perhaps, to establish correspond- 
ing varieties in the group, and the 
anterior oblique, everted dorsal, and 
supraspinous clearly belong in the same 
class by their mode of production and 
treatment. The class of supracotyloid 
dislocations, made by some writers to 
contain the two last mentioned, the rare 
dislocations directly upward, and some 

of the suprapubic, will be limited to those in which the head appears to 
have moved directly upward. The corresponding class and term of 



Fig. 120. 




The left hip-bone viewed from a point 
directly opposite the acetabulum. 



408 DISLOCATIONS OF THE HIP. 

" subcotyloid" must be retained for the rare dislocations downward " upon 
the tuberosity of the ischium." 

The terms upward and downward must not be taken too literally. 
They appear to have been rather carelessly used at first without strict 
regard to the normal position of the pelvis. When the body is upright, 
the upper border of the symphysis pubis lies a little below the level of 
the centre of the cotyloid cavity, and the tuberosity of the ischium lies 
not directly below this cavity, but below and behind. The classification, 
then, which will here be used is as follows : 

f dorsal, comprising the "iliac" and "ischiatic, " or 

those "upon the dorsum ilii" and "into the 

xv i ,. i 1 j i ischiatic notch " of the writers. 
Dislocations backward anterior ? ^. q ^ 

everted dorsal, comprising the " supra-spinou3 " 
[ and some of the "supra-cotyloid." 
Dislocations downward f obturator, 
and inward { perineal. 

Dislocations forward ) { j^" 

and upward J I * | intra-pelvic. 

Dislocations directly upward (supra-cotyloid or sub-spinous). 
Dislocations downward on the tuberosity of the ischium. 

As in the classification of dislocations of the shoulder, the names of 
the principal groups indicate the direction of the primary displacement 
and, consequently, the position of the rent in the capsule, and the names 
of the varieties show either the place at which the head of the femur 
comes to rest, or the special symptomatic feature which marks the 
variety. Kocher, 1 in an interesting and valuable paper, sought to establish 
a close analogy between the forms of shoulder and hip dislocations, but 
did not thereby, in my opinion, add anything to the precision of our 
knowledge, or the fulness or facility of comprehension. The only analogy 
that seems to justify mention is one created by the varying relations of 
the subscapularis muscle and the head of the humerus in the forward 
dislocations of the shoulder and those of the obturator internus and pyri- 
formis and the head of the femur in the backward dislocations of the hip. 

Backward Dislocations. 

1. Dorsal. 

2. Anterior oblique. 

3. Everted dorsal. 

In this class of dislocations the head of the femur in leaving the coty- 
loid cavity passes over its posterior margin at a higher or lower point 
while the limb is flexed, adducted, and rotated inward. ]n the great 
majority of cases the limb preserves this attitude, and the head rests not 
far from and behind, or behind and above, the margin of the acetabulum, 
between it and the great sciatic notch, or it may lie a little higher upon 
the concave surface of the ilium ; these constitute the dorsal variety, and 
include the "iliac" and " ischiatic " of other writers. In other cases 
external rotation of the limb takes place with or without abduction and 

1 Koeher : Volkmann's Sammlung klinische Beitrage, No. 83. 



BACKWARD DISLOCATIONS. 409 

extension ; in the latter case the limb crosses the opposite thigh and the 
toes are everted, the head of the femur lies above the socket, and the lower 
part of the neck corresponds to the upper and posterior margin of the 
acetabulum, the anterior oblique variety ; in the former case (with abduc- 
tion and extension) the outer branch of the Y-ligament is ruptured, the 
head of the femur lies above the socket, and the everted limb lies parallel 
to its fellow, or slightly abducted — the everted dorsal variety. The class 
includes all the backward dislocations of other authors, and most of those 
that have sometimes been grouped under the term " supracotyloid.' ? 

1. Dorsal dislocations. 

In these dislocations, which are, by far, the most common of all dis- 
locations of the hip, the head of the femur lies behind and above the 
cotyloid cavity, either close to and overlapping its edge (Malgaigne's 
" incomplete " form), or further away upon the ilium. It may pass below 
the obturator internus and rise behind it, or between it and the pyriformis, 
or above the latter, or both muscles may be completely torn across. The 
group, therefore, includes the dislocations " upon the dorsum ilii " and 
those "into the ischiatic notch" of Cooper, or the "dorsal" and the 
" dorsal below the tendon " of Bigelow's first classification, or the " iliac " 
and "ischiatic" of others. 

Causes. — Dorsal dislocations are commonly caused by violence that 
approximates the knee and the pelvis while the thigh is flexed, adducted, 
and rotated inward, as in a fall from a height, or in the fall of a heavy 
body upon the back of the patient while he is stooping forward. Less 
frequently but little or no violence acts to cause the over-riding of the 
femur upon the pelvis, and the dislocation is produced mainly or solely by 
flexion, adduction, and inward rotation, one of the three movements being 
exaggerated. Thus, in a case reported by Moffat, 1 the patient was drawing 
a railway carriage along the track ; he fell forward and rolled upon his 
back outside the rail to escape the car, but, as it passed, the end of the 
foot-board caught his leg and bent it upon and across his belly (flexion 
and adduction). The car had to be raised with a jack-screw to free him, 
and when released he was lying upon his back with the limb in the 
position described. When examined at the hospital, the thigh was slightly 
flexed and rotated inward, the toes overlapping those of the other foot, 
and there was shortening of half an inch. 

In a case reported by Dupuytren, exaggerated adduction appears to 
have been the chief factor. A delicate man, twenty-one years old, was 
thrown, while wrestling, upon his left side, and in the fall the left thigh 
was forcibly carried across the front of the other by the contact of the side 
of the knee with the ground. In a case observed by Malgaigne, and in 
another quoted by him from^ Mercier, exaggerated inward rotation ap- 
peared to be the principal cause ; both patients were women who slipped 
and twisted the foot inward while walking. 

A case, exceptional not only by its mode of production but also by the 
age of the patient, was reported by Bartels and has been referred to above. 

1 Moffat: Lancet, 1878, ii. p. 251. 



410 DISLOCATIONS OF THE HIP. 

The patient was a child eleven months old, and the dislocation was 
caused by the effort of a shoemaker to put on its shoe while it was sitting 
on its nurse's knee. 

In two cases in which the head was split into two pieces, one of which 
remained in the socket attached to the ligamentum teres (Moxon, p. 403, 
and Birkett, Chap. III., p. 31), it is evident that the flexion, adduction, 
and rotation were not carried far enough to turn the head out of the 
socket, and the dislocation, strictly speaking, was a complication of a 
fracture of the head produced by violent pressure of the inner segment 
against the outer and upper margin of the cavity ; in like manner the 
dislocation may be facilitated by the breaking off of a considerable portion 
of the acetabular ring. There is reason to think that some dislocations 
are produced in this manner by violence acting directly upon the upper 
part of the thigh, as in the passage across it of the wheel of a heavy 
wagon. 

It is by no means uncommon for a dorsal dislocation to be produced 
by the transformation of one downward and forward (obturator) during 
manipulations made to effect reduction, the head passing below and 
behind the acetabulum during flexion and adduction of the limb, and, in 
like manner, a dorsal may be transformed into an obturator dislocation. 

Occasionally dorsal dislocation takes place gradually while the patient 
is confined to bed by illness, especially by acute articular rheumatism 
and the infectious or eruptive fevers. These " spontaneous " dislocations 
will be considered in Chapter XXVII. 

Morris 1 expressed the opinion, formed after he had made a number of 
experiments upon the cadaver, that dorsal dislocation always took place 
while the thigh was abducted ; but although he showed that the capsule 
can be more easily ruptured by exaggerated abduction than by flexion, 
adduction, and inward rotation, yet that fact cannot for a moment support 
his opinion in the face of the overwhelming testimony that proves the 
common occurrence in the position of adduction and flexion. Indeed, 
Moffat's case, just quoted, was published to controvert Morris's opinion, 
and it seems to have passed without a reply from him. A similar 
opinion appears to have been published by Fabbri many years before ; 
but no author, so far as I have read, mentions the opinion except to 
express his disagreement with it. 

Pathology. — The condition of the capsule and of the muscles about the 
joint and the position of the head of the femur have been clearly shown 
by direct examination of a considerable number of specimens of recent 
dislocation, and by old ones, and by experiment upon the cadaver. 
Among the autopsies of fresh dislocations recently reported may be men- 
tioned those by Moxon, above quoted, MacCormac, 2 Adams, 3 Morris 
(loc. cit.), Lee, 4 and Humphrey, 5 w T ho describes three recent cases. 

The capsule is torn always in its lower posterior part, and usually also 
in its under part, but the rent varies greatly in extent and shape. 

1 Morris: Med.-Chir. Transactions, 1877, vol. 60, p. 161. 

2 MacCormac: St. Thomas's Hosp. Keports, 1871, vol. 2, p. 143. 

3 Adams: Trans. Path. Soc. of London, 1870, vol. 21, p. 305. 

4 Lee: St. George's Hosp. Reports, 1872-74, vol. 7, p. 169. 
6 Humphrey: Lancet, 1886, ii. p. 1011. 




BACKWAKD DISLOCATIONS. 411 

Frequently it lies about midway between the upper and lower posterior 
insertions of the capsule ; sometimes the capsule is torn away from the 
femur, and, rarely, away from the acetabulum. In Humphrey's three 
cases the rent had three branches radiating from a point " opposite the 
tuber ischii." Thus, he describes one as u a valvular rent in the under 
and back part of the capsule, commencing just behind the pubo-femoral 
ligament, midway between the acetabular and femoral attachments, as .a 
single tear which divided and extended upward and backward to the tuber 
ischii, and upward and forward to the trochanter near the attachment of 
the obturator externus ;" the rent in his second case w T as almost identical 
with that in the first; and that in the third is described as a "great 
vertical rent along the back of the capsule, nearer to its femoral than to 
its acetabular attachment, extending from the pubo-femoral ligament to 
the level of the fore part of the great trochanter, 
and there is a transverse rent under the position Fig. 121. 

of the gemellus inferior running from the vertical 
rent to the cotyloid ligament." 

In Morris's case (Fig. 121), "the capsule was 
ruptured on its lower and inner side, and was 
clearly peeled up from off the back of the neck 
of the femur as far as the digital fossa. The 
rent commenced below the pectineo-femoral 
band, midway between the acetabulum and the 
femur, and ran (1) outward and backward to the + . Mon ; s ' s ca ! e of A d0T f l ^ oca : 

7V/ 1#1 . it- * lon ; femur flexed and abducted 

neck of the latter, which it reached just above t0 show the rent in the capsule, 
and behind the small trochanter, and (2) inward 

and backward across the thin portion of the capsule toward the ace- 
tabulum which it nearly reached a little behind the ischial border of the 
cotyloid notch. It thus formed two sides of a large opening which was 
made quadrilateral in form by the detachment of the flap from the back 
of the femoral neck." 

In Lee's case the capsule was " freely lacerated all around, a small 
portion remaining attached to the femur in front and behind." This 
was, therefore, an "irregular" dislocation, and to the extensive laceration 
of the capsule corresponded a variation in the symptoms which fully cor- 
roborates Prof. Bigelow's views ; the report says : " Two of the main 
signs of dislocation were absent, namely, the advanced position of the 
knee with the foot resting upon the opposite one, and marked shortening." 
The head of the femur was below the pyriformis muscle and immediately 
behind the acetabulum. 

The preservation of the anterior portion of the capsule, the ilio-femoral 
ligament, is constant, as has been said, in the cases which Bigelow terms 
" regular," those which are marked by the common and characteristic 
symptoms of the dislocation, and, as he also pointed out, the strong 
portion of the capsule at its upper and posterior part is also usually 
untorn and opposes the ascent of the head upon the ilium. 

The ligamentum teres is usually torn from its attachment to the femur, 
but sometimes is ruptured. 

Of the muscles, the quadratus femoris is usually completely torn across, 
but sometimes (Humphrey's third case) is intact ; the gemelli commonly 



412 DISLOCATIONS OF THE HIP. 

are torn, but the obturator internus which is so closely associated with 
them frequently escapes or is only partly lacerated, probably because of 
its greater length. The pyriformis and obturator externus are sometimes 
torn partly or entirely across ; the glutei usually escape injury entirely 
or are only slightly lacerated. 

The head of the femur may lie close to the margin of the acetabulum, 
even overlapping the cavity, or it may be displaced to a variable distance 
backward or backward and upward. The lowest point at which its centre 
rests is the base of the spine of the ischium (Adams, loc. cit., and 
Quain 1 ) overlapping both sciatic notches ; and the highest, except perhaps 
in exceptional cases, appears to be opposite the apex of the great sciatic 
notch, which, in the recumbent position, is directly below the anterior 
superior spine of the ilium, the line uniting the two passing about an 
inch above the margin of the cotyloid cavity. Forty years ago Quain 
demonstrated by his autopsy (Fig. 127) the error contained in the name 
given by Sir Astley Cooper to the lower form of dislocation " into the 
sciatic notch," and formally called attention to it ; and a few years later 
Malgaigne showed that the head of the bone was much less upon the 
ilium in the higher form than was supposed, and further that in many, 
perhaps a majority, of the dislocations " upon the dorsum ilii " the femur 
left the socket at its lower posterior part and subsequently passed upward, 
so that in such cases the primary dislocation was " ischiatic," and the 
1 ' iliac " was secondary. This view has been amply confirmed. In 11 
specimens of old dislocations which Malgaigne examined, the head of the 
femur rose in 5 only to the level of a line drawn from the anterior superior 
spine of the ilium to the apex of the great sciatic notch, in 2 it rose half 
a centimetre above this line, in 2 one centimetre, in 1 one and a half 
centimetres, and in 1 two centimetres. There is no reason to suppose 
that in old dislocations the head is at a lower level than in recent ones, 
indeed it is probably somewhat higher. 

When the head of the femur leaves the socket at its lower part it 
passes usually below the obturator internus and then rises behind it, so 

that this muscle is interposed between 
Fig. 122. it and the acetabulum (Figs. 122 and 

123). Or it may be immediately beneath 
Piriformis jf^ llj^ the obturator internus and press it 

forcibly upward, as in Adams's case 
(Fig. 124), which remained unreduced 
until the patient's death on the fourteenth 
day, and in which the muscle was so 
v tightly stretched over the upper part of 

| m ' xl ' the head that a deep groove had formed 
in the articular cartilage of the latter 
exactly corresponding in size and direc- 
tion to the tendon ; the head rested on 

Dislocation below and then behind and , . „ , . , . -. , , 

above the obturator internus. the spine of the ischium, and the obtur- 

ator externus and quadratus femoris 
were ruptured. Or the head may pass above the obturator internus, 
between it and the pyriformis, as in MacCormac's case (Fig. 125) in 

1 Quain: Med. Chirurg. Trans., 1848, vol. 31, p. 337. 




BACKWARD DISLOCATIONS. 



413 



which it rested " behind the acetabular ridge opposite the middle and 
upper part of the great ischiatic foramen, behind the posterior border of 
the gluteus medius, and only covered by the gluteus maximus and the 
integument/' This is an example of a real primary " iliac " dislocation, 
and the rent in the capsule was "merely on the back part, and the neck 
was as it were locked over the acetabular ridge, and the strong anterior 
part ot the capsule was tightly stretched." Figure 126, representing a 
specimen obtained experimentally by Bigelow shows the untorn anterior 
and lower portion of the capsule in this form. 



Ftg. 123. 



Ftg. 124 





. : >m« 

HI' 

Adams's case; a, head of femur ; b f 
lfP*' obturator exterrms ruptured ; c, quad- 

ratus femoris ruptured ; d, sciatic 
Dorsal dislocation below the obturator internus (Bigelow.) nerve. 

The edge of the acetabulum is sometimes chipped, and in two of the 
cases above quoted (Quain, Morris) there was a fracture through the ilium 
into the cotyloid cavity, and in the latter there was also a fracture of 
the ramus of the ischium. In both cases the injury was caused by great 
violence. 

In a case reported by Birkett, and quoted in Chapter III., the head 
of the femur was split vertically, the inner half remaining in the acetab- 
ulum and still attached to the ligamentum teres, and the other, con- 
tinuous with the neck, being displaced backward above the obturator 
internus. A similar case, quoted above among compound dislocations, p. 
403, was reported by Moxon ; and in another reported by Riedel and also 
quoted in Chapter III., p. 32, the head and neck were split longitudinally, 
both fragments being displaced from the socket. In a case seen by Lossen 1 
the neck of the femur had been broken at the moment of dislocation, but 
doubtless after the head of the bone had left the socket. In several 
reported cases the neck has been broken during an attempt to reduce. 



1 Lossen : Deutsche Chir., Lief. 65, p. 55. 



414 



DISLOCATIONS OF THE HIP. 



and in a few in which fracture has been recognized it has remained 
uncertain whether it occurred simultaneously with the dislocation or was 
caused by the surgeon. (See Chapter XXVII.) 



Fig. I! 



Fig. 126. 




MacCorinac's specimen of recent dor- 
sal dislocation. The head of the femur 
lies just behind the acetabulum, below 
the pyriformis and above the obturator 
interims and the torn gemellus muscles. 




Dorsal dislocation ; showing the anterior 
part of the capsule. (Bigelow.) 



The sciatic nerve commonly lies behind the head of the femur and at 
the most is only slightly pressed upon, but in Quain's case it was stretched 
over the neck of the femur (Fig. 127) " having passed into contact with 
the bone in the interval between the fragments of the quadratus-femoris. 
Between the nerve and the bone was the torn tendon of the obturator 
externus." The nerve has been found in a similar position in some 
experiments upon the cadaver. 

Symptoms. — The patient is unable to bear his weight upon or voluntarily 
to move his injured limb ; if he stands upright it shows moderate flexion 
and adduction, marked inversion, and more or less shortening, the toes 
resting on those of the other foot. When he is placed upon his back the 
apparent adduction and flexion are increased, the knee resting just above 
the other patella or crossing the thigh at a higher point. The contours 
of the outer and posterior regions of the hip are changed by loss of the 
normal depression behind the trochanter, elevation of the gluteal fold, 
and abnormal fulness due to the approximation of the insertions of the 
gluteal muscles. The trochanter rises to a variable distance above the 
line drawn from the anterior superior spine of the ilium to the tuberosity 
of the ischium, and its distance from the first named prominence is 
increased. The head of the femur can be obscurely felt through the 
gluteus maximus and recognized by its movement when the limb is flexed 
or rotated. The empty socket cannot be felt from in front, because it is 
covered by the anterior portion of the capsule and the psoas and iliacus, 
but the depressibility of the soft parts in Scarpa's space is as great as, or 



BACKWARD DISLOCATIONS, 



415 



greater than, that on the opposite side, whereas in fracture of the neck 
of the femur this depressibility is diminished. 



Fig. 121 



Fig. 128. 




Quain's case of dorsal dislocation below and then behind the obturator 
internus ; the sciatic nerve, held by the hook, is stretched over the 
neck of the femur. 



Dorsal dislocation. 



The limb can be still further adducted and flexed, but it cannot be 
abducted or rotated outward. The apparent shortening varies greatly in 
degree in different cases, and the actual shortening cannot always be 
determined with accuracy because of the difficulty of placing the limbs 
symmetrically. Concerning this shortening the most contradictory state- 
ments have been made ; some surgeons, relying solely upon the appear- 
ance of the limb and seeing that the knee lay well above the opposite one, 
have described the shortening as great ; others, looking only to the new 
relations of the bones as shown upon the skeleton, have described the 
shortening as moderate, or even as absent in the lower forms. The error 
in the first arises from not taking into account the effect of adduction to 
create an apparent shortening of the adducted limb when compared with 
its non-adducted, still more with its abducted, fellow ; that in the second 



416 



DISLOCATIONS OF THE HIP. 



arises from considering the question only with reference to the position 
of extension. If the head of the femur is displaced backward toward the 
spine of the ischium, the length of the limb measured in extension from 
the anterior superior spine of the ileum to the knee or ankle will not be 
diminished, for the movement backward of the head has been at right 
angles to the line of measurement and has not brought the knee any 
nearer to the pelvis ; but if the measurement is made while the thigh is 
flexed at about a right angle the measured length will be less by about 
two inches than that of the other limb in the same position, for now the 
measured line is nearly parallel to the direction of displacement. When 
the head is displaced upward as well as backward the difference in the 
amount of shortening in these two positions of the limb is much less, for 
the direction of the displacement deviates at about the same angle from 
the measured line in each attitude. Of course, in each limb the measured 
length is less when the thigh is flexed, but the difference in the compara- 
tive measurements of the two limbs is not affected in the high dislocations 
and is greatly affected in the low ones. In making measurements the 
two limbs must be symmetrically placed as regards flexion and adduction, 
and the fixed adduction of the injured limb sometimes interferes seriously 
with the accomplishment of this condition, for its knee occupies the posi- 
tion to which the other one should be brought, and, therefore, an equal 
adduction cannot be given to the sound limb without carrying its knee 



Fig. 129. 



Fig. 130. 





"Dorsal dislocation, downward and outward toward the 
Dorsal dislocation below the tendon. tuberosity. . . A first step to luxation behind the tendon, 
The flexion is greater when the patient which it inclines to become when the patient is upright." 
is recumbent. (Bigelow.) (Bigelow.) 



across at a higher or lower level, and thus giving it an unsymmetrical 
flexion. It must also be remembered that apparent symmetry of position 
is not sufficient, the symmetry must be real in that the angles of flexion and 
adduction on the pelvis are the same. Fortunately the exact determina- 
tion of the shortening is not necessary to the diagnosis of the dislocation. 
When the head passes below the tendon of the obturator internus and 



BACKWARD DISLOCATIONS. 417 

does not secondarily rise upon the ilium the inversion and flexion of the 
limb are greater than when the head comes to rest at a higher point (Fig. 
129) and may be so great that the limb crosses the opposite thigh as 
high as its middle (Fig. 130). The flexion may be so masked by the 
tilting of the pelvis that the thigh will lie nearly alongside the other, 
parallel to the long axis of the body, but the condition can be recognized 
by attention to the compensatory curve (lordosis) of the lumbar vertebrae ; 
indeed, Syme 1 said he made the diagnosis of ischiatic dislocation without 
other handling of the patient than that necessary to recognize the lordosis. 

The cause of the comparative fixation of the limb, of its attitude, and 
of the loss of even passive abduction and external rotation was first clearly 
shown by Prof. Bigelow in his classical monograph upon the Hip. Others 
had recognized, in a measure, the part taken by the strong anterior 
portion of the capsule in determining the attitude of the limb, but he was 
the first to study the subject in all its bearings and to present a complete 
account of the relations and influences of the Y-ligament in all forms of 
dislocation, one which was at once and everywhere accepted and has been 
made the basis of the present methods of reduction. He says (loc cit., p. 
38), " The inversion is chiefly due to the outer branch of the Y-ligament, 
as is shown by the fact that the characteristic sign disappears when this 
branch is divided. But other parts of the capsule, varying with its laceration, 
may assist the inversion of the limb, and when the latter is exaggerated, as 
when one thigh crosses the other at its middle or upper third, they may seem 
to be largely concerned in it ; thus, if the dorsal luxation is secondary to 
one below the socket, only the anterior and superior fibres will remain 
untorn ; while, if the femur has been thrust obliquely upward and back- 
ward, attachments may be found at both the anterior and the inferior 
margins of the acetabulum. But it is unnecessary to consider these lesser 
and comparatively slender fibres. In such cases, the knee can be de- 
pressed, as indeed it often is, by the forces to which it is subjected at the 
time of the accident, until the exaggerated flexion and inversion have 
disappeared, and if even a large part of the capsule, as in the annexed 
figure [Fig. 126] is stretched tense across the socket, it may then be rup- 
tured without diminishing the inversion, which, for all practical purposes, 
is due to the outer branch of the Y-ligament." 

Diagnosis. — The recognition of the character of the injury is rarely 
difficult. The group of prominent symptoms — loss of function, adduc- 
tion, inversion, and flexion of the limb, resistance to abduction, exten- 
sion, and outward rotation, elevation of the trochanter above Nelaton's 
line — are not found in any other affection except perhaps hip-joint 
disease of long standing. The mistake most frequently made is that of 
confounding it with a fracture of the neck of the femur, or, to speak 
more definitely, is that of supposing a fracture of the neck to be a dislo- 
cation. I have met with several instances of this, some of which led to 
litigation. The differences between the symptoms of the two injuries are 
striking and usually sufficient to make the mistake impossible if ordinary 
attention is paid to them ; the fixity of the limb in dislocation, with the 
knee thrown forward and inward against or upon the opposite thigh, the 

1 Syme : Lond. and Edinb. Monthly Journal, 1843, vol. 3, p. 498. 

27 



418 DISLOCATIONS OF THE HIP. 

prominence of the trochanter, and, usually, its increased distance from the 
anterior superior spine of the ilium, contrast strongly with the straight, 
everted, powerless limb and flattened hip of fracture of the neck. Frac- 
tures with inversion and dislocations with eversion are entirely excep- 
tional. When the two injuries have coexisted the diagnosis has sometimes 
been made by recognizing that the head, which could be felt out of its 
place, did not share in the movements communicated to the shaft, 1 and 
sometimes by the splitting and enlargement of the great trochanter. 

2. Everted dorsal dislocations. 

In this class, of which there are but few recorded cases, are here 
included Bigelow's anterior oblique, everted dorsal, and supraspinous. 
It is characterized, as the name indicates, by eversion of the limb in 
place of the inward rotation which is so prominent a feature of the common 
dorsal dislocation, and this symptom is due in all cases, except perhaps 
the very rare anterior oblique, to rupture of the outer branch of the 
Y-ligament. In the supraspinous variety the head of the bone lies above 
the anterior inferior spinous process of the ilium in the notch between it 
and the superior spine. 

Although occasional cases had been previously reported, the variety 
was not described by systematic writers before Prof. Bigelow, and was 
not even mentioned by Malgaigne, although possibly one or two of the 
cases classed by him as supracotyloid may have been of this kind. In 
a paper by Blasius 2 on supracotyloid dislocations several cases of this 
variety (everted dorsal) are included, together with others in which the 
head had reached nearly the same position by passing outward after 
primary dislocation forward and upward upon the pubis, and a few in 
which the dislocation was primarily directly upward. The same grouping 
has been followed by other writers, and in no reported case previous to 
1850 does it appear to have been recognized that the head had reached 
this position by a secondary displacement after dislocation backward and 
upward. Blasius's paper, although published in 1874, must be classed 
with those of an earlier period, for it is really the republication of researches 
made some time earlier by his son in a graduating thesis, and it makes 
no mention of Prof. Bigelow's work. It is, in one respect, a publication 
to be regretted, for the authority of its writer and its date combine to 
further the acceptance without examination of the grouping, or classifica- 
tion, which cannot properly be accepted in view of the important patho- 
logical differences between the individual cases of which it is made up. 

The earliest recorded case I have found is a doubtful one reported by 
Morgan 3 in 1836 ; the patient was a man sixty-six years old, who had 
fallen backward down-stairs while helping to carry a heavy object. " The 
left leg was shortened to the extent of at least two inches ; the foot 
excessively everted, so as almost to give the toes a direction backward. 
The injured limb had a tendency to cross that of the opposite side, so as 
to throw the heel over the instep of the opposite foot ; nevertheless, when 

1 Koch : Berlin, klin. Wochenschrift, 1882, p. 492. 

2 Blasius: Arch, fur klin. Chir., 1874, vol. 16, p. 207. 

3 Morgan: Guy's Hosp. Eeports, 1836, vol. 1, p. 79 



BACKWAED DISLOCATIONS. 419 

they were placed side by side they remained in that position. The leg 
was susceptible of all the natural motions to some extent, with the excep- 
tion of rotation, but the man comp]ained of great pain while under exami- 
nation. The projection of the great trochanter was entirely lost; whilst 
the luxated head of the bone might be felt under Poupart's ligament, just 
below and to the inner side of the anterior and superior spinous process 
of the ilium, and apparently lying between the anterior inferior spinous 
process of the ilium and the junction of that bone with the pubis." It 
was reduced by traction, flexion, and rotation inward. 

Other cases were reported during the next following ten years by 
Travers, 1 a pupil in St. George's Hospital, 2 and Gordon. 3 The report of 
the second of these was accompanied by an account of the autopsy, and 
Cadge 4 subsequently reported the autopsy in Travers's case. This case 
is quoted twice by Sir Astley Cooper, once (loc. cit., p. 79) as a disloca- 
tion on the pubes, which was also Cadge's diagnosis, and once (loc. cit., 
p. 88) as a dislocation directly upward, quoting Travers. Bigelow also 
quotes it as two cases (loc. cit., p. 96), and reproduces Cadge's plate of 
the os innominatum, showing the new socket (Fig. 131). There is some 
reason to think the dislocation may have been directly upward. There 
are a few other cases variously reported either as dislocations upon the 
pubis or as dislocations directly upward, which may be of the same 
character, but the descriptions do not permit a positive diagnosis. 

In 1850 the possibility of the production of this form by transformation 
of a dorsal dislocation was shown in an attempt made in the New York 
Hospital to reduce a dislocation " into the sciatic notch." The case is 
reported by Lente ; 5 after traction had been made and suddenly relaxed 
the thigh was abducted and rotated outward, and this brought the head 
of the femur above the acetabulum, and below the anterior superior spinous 
process ; the shortening w T as then about two inches ; the limb very much 
rotated outward, the rotundity of the hip greater than that of the other, 
and the trochanter major one inch further from the anterior superior spinous 
process. 

Five years later Van Buren 6 observed in the same hospital a case 
which, so far as I know, was the first in which the absence of inversion 
and marked adduction was noted in a case recognized as a dorsal disloca- 
tion. The limb "was shortened about an inch; the foot and leg were 
slightly everted. This eversion, it was afterward ascertained, could be 
readily increased by manipulation ; but there was an evident obstacle at 
the hip to inversion of the foot. The knee was slightly flexed, so that 
the width of the hand could be readily passed between its popliteal aspect 
and the surface of the bed. The obliquity of the femur toward its fellow 
was very slightly increased. Upon the front of the thigh at its upper 
third a very manifest concavity or sinking in was noticeable, the usual 

1 Travers: Med. Chir. Trans., 1837, vol. 20, p. 112. 

2 Lancet, 1840-1, vol. 2, p. 281. 

3 Gordon: Dublin Hosp. Gazette, 1844-5, vol. 2, p. 85. 
* Cad<?e: Med. Chir. Trans., 1855, vol. 38, p. 88. 

5 Lente: N. Y. Journal of Med., 1850, p. 314. 

6 Van Buren : N. Y. Med. Times, 1856, vol. 5, p. 126, and reprinted in his Contri- 
butions to Practical Surgery, p. 157. 



420 DISLOCATIONS OF THE HIP. 

anterior convexity of the limb being lost. The trochanter was about an 
inch and a half behind and above its usual position, and, during etheriza- 
tion, it was quite movable on attempting rotation of the limb. Finally, 
the head of the femur could be felt obscurely but pretty certainly rotating 
in the ischiatic notch, low down, and in contact with its posterior margin. 
The anterior convexity of the spine at the loins was also very much 
increased, so that under ether more than the width of the hand could be 
passed between it and the surface of the bed. Thus the case presented 
all the classical features of luxation into the ischiatic notch, and more 
than usually well marked, with the exception of adduction of the lower 
end of the femur and inversion of the foot." After several failures to 
reduce by manipulation and traction downward, reduction was effected 
by traction while the limb was flexed at right angles to the pelvis, followed 
by abduction and extension. 

In 1864 Symes 1 reported a case, and suggested for the variety the 
name of " dorsal with eversion." This was subsequent to Bigelow's 
researches but previous to his publication of them, except in his lectures. 
The limb was shortened two inches, the foot extremely everted, the 
buttock flattened, and the head of the femur two inches below the anterior 
superior spine of the ilium. By flexion of the limb the dislocation was 
made dorsal, and a feature of special interest is that then, as the limb lay 
untouched upon the table, eversion gradually took place under the influ- 
ence of gravity, and the head returned to its former place. 

In 1874 Kocher 2 observed a similar case in a woman, forty-nine years 
old ; the limb was fully extended, markedly everted, and shortened three 
centimetres ; the head could be felt below and to the outer side of the 
anterior superior spine of the ilium. By flexion and inward rotation the 
dislocation became dorsal with the characteristic symptoms, and then by 
extension and outward rotation the original symptoms were reproduced. 

Pathology. — At the autopsy in the fresh case observed at St. George's 
Hospital, the head of the femur lay about an inch below and to the outer 
side of the anterior superior spinous process of the ilium, and the tro- 
chanter was still further to the outer side and behind, resting on the 
dorsum of the ilium, so that the toes pointed outward and slightly back- 
ward. The gluteus medius and minimus were extensively lacerated and 
nearly torn through at about two inches from their attachment to the 
trochanter ; the gemelli and quadratus femoris were slightly lacerated ; 
the capsular ligament was extensively lacerated at its upper part, and the 
ligamentum teres ruptured. The trochanter minor rested on the outer 
edge of the acetabulum. In a case which I reported to the New York 
Surgical Society, December, 1887, and January, 1888, 3 which had been 
subjected to many attempts to reduce, the outer branch of the Y-ligament 
was ruptured and the muscles behind the trochanter extensively lacerated. 
Complete reduction was prevented by interposition of tlfe anteroinferior 
part of the capsule. In Cadge's autopsy of Travers's case (Fig. 131), 
the head of the femur lay in the interval between the anterior superior 

1 Symes: Dublin Quart. Journ. Med. Sci., 1864, vol. 38, p. 272. 

2 Kocher: Volkmann's Sammlung klin. Vortrage, No. 83, p. 631. 

3 Stimson : N". Y. Med. Journ., Jan. and Feb. 1888. 



BACKWARD DISLOCATIONS, 



421 



Fig. 131. 



and anterior inferior spinous processes of the ilium, and was covered by 

a complete bony cap lined with a dense, pearly white tissue resembling 

fibro-cartilage. The edge of the 

new cavity was connected with the 

neck of the thigh bone by a thick 

capsular ligament. The rectus 

muscle, which had been torn from 

its origin, was inserted upon the 

edge of the new cavity, a condition 

which, as Bigelow says, suggests 

the ascent of the bone above the 

inferior spinous process of the 

ilium at the time of the injury, 

with rupture of the Y-ligament. 

Van Buren's case, and a very 
similar one reported by Annan- 
dale, 1 show that the head may lie 
much further to the outer side, at 
or near the sciatic notch. 

Bigelow's experiments show 
that this eversion depends upon 
the rupture of the outer branch 
of the Y-ligament. The head of 
the femur escapes at the back of 
the joint while the limb is flexed, 
adducted, and rotated inward, 
and then by external rotation the 
outer branch is torn; if, then, the 
head remains in its position opposite or below the sciatic notch, the 
position and symptoms are such as are noted in Van Buren's and 
Annandale's cases, the flexion and slight adduction being due to the 
remaining untorn branch of the ligament. The change in the position of 
the head noted in the other cases Bigelow was able to reproduce experi- 
mentally from a common dorsal dislocation by carrying the limb "across 
the symphysis, so that the outer and convex surface of the socket shall 
correspond to the hollow beneath the neck of the femur. With some 
force the thigh can now be everted, and afterward brought down across 
the upper part of its fellow." (This is the form to which he gave the 
name "anterior oblique.") "If, in this position, it is desired to bring 
the limb toward a perpendicular, the outer branch of the Y-ligament 
must be ruptured. Thus liberated, it hangs suspended by the inner 
ligament, and becomes capable of lateral motion and of rotation ; and 
this is probably the condition under which supra-spinous luxation, 
although rare, usually occurs." Fig. 132 shows in the dotted lines the 
head of the femur thus hooked over the remaining part of the ligament. 

The anterior oblique is a variety which I feel some hesitation in pre- 
serving, because Bigelow appears to have observed it only in experiments 
upon the cadaver, and to have known of only one recorded case (Oldnow, 




Old everted dorsal dislocation. Oadge's case, a, new 
bony cap, with its fractured margin, b. 



Annandale: Lancet, 1876, i. p. 208. 



422 



DISLOCATIONS OF THE HIP. 



in Guys Hospital Reports, 1836, vol. i. p. 97) in which the attitude 
resembled that found in his experiments. The specimen in that case 



Fig. 132. 



Fig. 133. 




Supraspinous dislocation. When the femur takes the 
position indicated by the dotted line, only the inner branch 
(>f the Y-ligament remains untorn. (Bigelow.) 




Anterior oblique dislocation. 
Oldnow's case. 



is represented in Fig. 133. Figs. 134 and 135 show the attitude and 
specimen obtained from the cadaver ; the mode of production has been 
quoted in the preceding paragraph. The Y-ligament is untorn. If the 



Fig. 134. 




'iirrrrrirmn-m,i,TiivS.— =• - 
Anterior oblique dislocation. (Bigelow.) 



primary dorsal dislocation has been below the tendon of the obturator 
internus, this muscle is ruptured in the subsequent change of place. 

The symptoms of the everted dorsal may be the same as those of the 
common dorsal dislocation, with the exception that there is marked or 



BACKWARD DISLOCATIONS. 



423 



slight eversion of the limb instead of inversion ; or, if the head of the 
femur has moved forward above the anterior inferior spinous process, 
they may differ widely, for the limb is then shortened about two inches, 
slightly abducted, more or less everted, and fully extended (Fig. 136). 
The eversion of the limb is liable to lead to the mistake of supposing 
the injury to be a fracture of the neck of the femur, especially in the 
cases in which the head is brought forward above the acetabulum and in 



Fig. 135. 



Fig. 136. 





Anterior oblique dislocation. (Bigelow.) 



Everted dorsal dislocation. (Bigelow.) 



which the limb is also extended. The greater fixation of the limb and 
the recognition of the position of the head and of its continuity with the 
shaft, as shown by its sharing in the movements communicated to the 
latter, will establish the diagnosis. 

The rupture of the outer branch of the Y-ligament is the explanation 
of the failures noted in some of the cases to reduce by manipulation alone ; 
traction in the flexed position is needed to bring the head forward into 
the socket; abduction fails to do it because of the loss of the support of 
the outer branch of the ligament. 

Treatment. — The method of reduction so long in use, and which left 
so many dislocated hips unreduced, that in which it was sought to draw 
the bone into place by traction upon it with compound pulleys while the 
limb was almost as fully extended as possible, has at last been abandoned 
in favor of the methods of simple manipulation or of moderate traction in 
the flexed position, or of a combination of the two. The advantages of 



424 DISLOCATIONS OF THE HIP. 

the flexed position, the possibility of reducing by the aid of moderate 
traction when the thigh is flexed at a right angle with the trunk, were 
repeatedly pointed out by different writers during the last century and 
the first half of the present one, and the possibility of reducing by 
manipulation alone (flexion, outward rotation, and abduction) was also 
demonstrated, but neither seems to have had any influence in modifying 
the general practice, although some surgeons, notably Prof. Nathan 
Smith, of New Haven, taught and habitually practised traction with the 
limb flexed at a right angle, and he also, in 1831, formulated a method 
by manipulation alone. 

Despres, 1 in 1835, independently formulated the method by flexion 
and outward rotation; and Reid, 2 in 1851, did the same, preceding the 
flexion with marked adduction; but they assumed that the principal 
obstacle to reduction lay in the resistance of the muscles, and their 
manipulations were designed to overcome or avoid this. 

Bigelow 3 quotes Smith's description of this method by manipulation 
from his Medical and Surgical Memoirs, edited in 1831 by his son, 
Nathan R. Smith, as follows : " The first effort which the operator 
makes is to flex the leg upon the thigh, in order to make the leg a lever 
with which he may operate on the thigh bone. The next movement is a 
gentle rotation of the thigh outward, by inclining the foot toward the 
ground, and rotating the knee outward. Next, the thigh is to be slightly 
abducted by pressing the knee directly outward. Lastly, the surgeon 
freely flexes the thigh upon the pelvis by thrusting the knee upward 
toward the face of the patient, and at the same moment the abduction is 
to be increased." Bigelow adds " this covers the ground of priority 

of invention. It belongs to Nathan Smith In 1835, 

Despres, and in 1852, Reid, of Rochester, enunciated the same views, 
the practice was good, but both Prof. Smith and Dr. Reid based the 
method and sought its mechanism in the erroneous theory of muscular 
resistance." 

After 1850 the attention of surgeons and anatomists began to be 
directed more specifically to the opposition offered by the untorn portions 
of the capsule and to the position of the rent in it, and many experiments 
were made upon the cadaver to obtain a more accurate knowledge of the 
matter. Among these may be mentioned those of Meyer, 4 Gunn, 5 
Roser, 6 Bigelow, 7 Gelle, 8 Busch, 9 and Tillaux. 10 Of these Bigelow's 
researches were by far the most complete and accurate, and to his classical 
work must be referred the popularization and general acceptance of the 
views now held and the methods of treatment based upon them. The 
importance of the anterior portion of the capsule, the Y ligament, had 

1 Despres: Bull, de la Soc. Anatomique, Sept. 1835, p. 4. 

2 Kpid : Buffalo Med. Journal, Aug. 1851. 

3 Bigelow: Lancet, 1878, I. p. 861. 

4 H. Meyer : Zeitschrift fur rat. Med., 1850, vol. 9, p. 250. 

5 Gunn : Penins. Journ. of Med., 1853-4, vol. i. p. 97. 

6 Koser: Archiv fur Phys. Heilkunde, 1857, vol. i. p. 42. 

7 Bigelow: The Hip, 1869. Experiments made in 1860. 

8 G-elle: Arch. gen. de Med., 1861. 

9 Busch : Arch, fur klin. Chir., 1863, vol. iv. p. 11. 
10 Tillaux: Bull, de la Soc. de Chir., 1868, p. 274. 



BACKWARD DISLOCATION'S. 425 

indeed been specifically pointed out by one or two earlier writers — it is 
mentioned in Hyrtl's Topographisclie Anatomic, in Meyer's paper in 
1850, and by von Pitba 1 in 1863 — but Bigelow was the first to study its 
influence in detail, to show its constant action in all typical forms, and 
to base upon it methods of reduction for the different forms, and to him 
belongs the credit not only of independent discovery but also of the still 
more important benefit conferred by impressing the facts upon the pro- 
fession by his careful, thorough investigations and his clear exposition of 
the facts and principles. 2 

It is now generally recognized that the chief obstacle to reduction is 
created by the tension of the Y-ligament in the partly extended position 
of the limb, and that this is to be removed by flexion of the limb upon 
the trunk. At the same time the movement of flexion brings the head 
of the femur down along the back of the acetabulum so that it lies 
opposite the opening in the capsule if, as is usually the case, it has left 
the socket at its lower posterior part and has risen to a higher level by 
the subsequent extension of the limb, enlarging the rent upward in the 
movement ; if, more rarely, the head has left the socket at a higher level 
while the limb w r as only slightly flexed, this movement of flexion in 
reduction, unless carried beyond a right angle, does not place the head 
below the opening, or at least, if it does so, the movement enlarges the 
rent downward so that the way is still open for the return of the head to 
its place. Another reason for making this movement is found in some 
cases in the interposition of the obturator internus between the head and 
the socket, the cases, so-called, of "dislocation below the tendon" in 
which the head has secondarily risen toward the dorsum ilii. During 
the movement the adduction and internal rotation of the limb are pre- 
served or even somewhat increased in order to lift the head of the femur 
away from contact with the pelvis and from behind the projecting rim of 
the acetabulum. 

The directions given by Bigelow in his first publication (loc. cit., p. 46) 
are as follows : 

" By Traction. Lay the patient, w T hen etherized, on his back upon 
the floor, bend the limb at the knee, flex the thigh upon the abdomen, 
adduct and rotate it a little inward, to disengage the head of the bone 
from behind the socket. The Y-ligament is then relaxed. 

" If the bone can now be abducted beyond the perpendicular, the 
capsule and other tissues are probably so torn or relaxed that reduction 
may be accomplished without much difficulty : the thigh need only be 
forcibly lifted or jerked toward the ceiling, with a little simultaneous 
circumduction or rotation outward, to direct the head of the bone toward 
the socket." 

In his later paper, in the Lancet, 1878, he gives them more briefly in 
the following terms : 

" 1. Flex and forcibly lift. If this fails, 

1 Von Pitha: Pitha and Billroth's Chirurgie, vol. iv. part 2, B, p. 161. 

2 The claim of priority in the discovery of the part played by the anterior por- 
tion of the capsule made for Prof. Gunn, of Chicago, is, I think, sufficiently 
answered bv Prof. Bigelow in a letter published in the Chicago Medical Examiner, 
January, 1870, p. 25. 



426 DISLOCATIONS OF THE HIP. 

"2. Flex and lift while abducting. If this fails, it will be found that the 
rent in the capsule has been so enlarged that the first method may now 
prove successful." 

Bigelow adds to his first description three other methods of making 
the manipulation and applying the force, and, although the mechanism is 
the same in all, the multiplicity of the directions has been criticised by 
recent German writers, who seem to regard the four as essentially 
different from one another. 

Kocher, 1 after making this criticism, describes what he calls his own 
method, and this is quoted approvingly by Albert and Konig. Its 
identity with Bigelow's appears to me to be complete, although it com- 
bines his two methods by traction and by manipulation. It is as follows : 

1. Inward rotation to relax the capsule and lift the head from, the 
posterior surface of the pelvis. 

2. Flexion, to a right angle and gently, preserving the existing 
adduction and inward rotation. 

3. Traction, to make the capsule tense, so that it can be utilized in 
the following movement, and to raise the head to the level of the 
acetabular margin, thus overcoming the action of gravity. 

4. Outward rotation ; this makes the posterior part of the capsule and 
outer band of the Y-ligament tense, and turns the head forward into the 
socket. 

Bigelow's directions for reduction by manipulation are as follows (loc. 
cit., p. 48) : 

Flex the thigh and abduct or circumduct it outward, at the same time 
rotating it outward. The head of the bone, revolving about the great 
trochanter which is fixed by the outer branch of the Y-ligament, rises 
over the edge of the socket into its place, unless the capsule is interposed, 
in which case the opening must be enlarged by making the limb form a 
large angle laterally with the trunk, a movement which will probably 
convert the dislocation into a thyroid one, by causing the head to pass 
below the acetabulum to the obturator foramen ; if it is then restored to 
its former position by reversing the manipulation, a second attempt may 
succeed. Care must be taken not to rotate outward before the abduction 
is complete, so as to avoid the needless passage of the head below the 
socket to the obturator foramen. 

The following is his explanation of the mechanism by which reduction 
is thus effected. " When the thigh is forcibly flexed upon the abdomen, 
the head of the bone is lifted out from beneath the socket. A little 
inward rotation favors the same result. If the thigh be now slowly 
abducted or depressed outward, it is plain that the head of the bone, 
suspended by the Y-ligament, must rise toward the socket, and that, 
when the shaft is thus abducted, outward rotation assists the entrance of 
the head. If the head of the bone is above the tendon of the internal 
obturator, this outward circumduction also ruptures the small rotator 
muscles. It may be needless to say that, were the head of the bone 
suspended by the dissected Y-ligament alone, a lateral movement of the 
knee would perhaps cause the head of the bone to swing from side to 

1 Kocher: Volkmann's klinische Vortrage, No. 83. 



BACKWARD DISLOCATION'S. 427 

side, instead of giving to it the desired upward tilt. This movement is 
hindered by the unruptured fibres on each side of the Y-ligament, which 
continue to a greater or less extent in the different dislocations, and 
contribute to the varying facility with which different cases are reduced. 
This is especially true of the dislocation behind the tendon of the obturator 
internus, where the posterior part of the capsule not unfrequently remains 
uninjured." 

There are a number of practical points connected with the carrying 
out of these directions which require attention. The pelvis may need to 
be steadied or immobilized during traction, in order that the limb may 
not be too soon or unwittingly abducted, and this may be done either by 
the hands of assistants or by the pressure of the surgeon's foot upon the 
anterior superior spinous process of the ilium of the injured side while 
he is lifting the thigh. 

The traction upon the thigh may be made by the hands of the surgeon, 
but if the patient is a muscular adult the force that can be thus exerted 
may be insufficient, and it can then be conveniently supplemented by 
making the two ends of a bandage fast to the thigh above the knee and 
placing its loop over the surgeon's neck upon his shoulders. 

Or the patient may be placed face downward upon a table in such a 
way that the injured thigh will hang down at the end, the sound thigh 
being supported horizontally by an assistant or resting on another table 
brought up against the foot of the first one. In this position the weight 
of the limb furnishes the necessary traction, which, if need be, can be 
supplemented by pressure with the hand upon the calf of the flexed leg, 
and the required rotation and abduction can be easily made. In this 
manner I once quickly and easily reduced, without anaesthesia, a recent 
dislocation in a very muscular young man. 

External rotation must be carefully avoided during the first steps, lest 
it should convert the dislocation into an everted dorsal by throwing the 
head forward above the socket ; and extreme flexion and abduction 
without simultaneous traction are also to be avoided in order to escape 
the conversion of the dislocation into one upon the obturator foramen by 
the passage of the head below the socket. This accident has been 
frequently observed, and, when it has occurred, traction upon the flexed 
thigh should, I think, always be preferred to pure manipulation. 

The everted dorsal and anterior oblique dislocations are reduced after 
first converting them into the dorsal form. This conversion is effected in 
the former by flexion and inward rotation, with adduction, if necessary, 
to make room for the head of the bone to slide upon the ilium ; the 
rupture of the outer branch of the Y-ligament deprives the operator of 
much of the advantage of rotation, and the dislocation must, therefore, 
be reduced by direct traction toward the socket, with local guidance of 
the head. In my own case, in which, after conversion into the dorsal 
form the tendency of the head again to pass forward above the acetabu- 
lum was very marked, outward rotation had to be carefully avoided. 
The anterior oblique is transformed by inward circumduction of the ex- 
tended limb across the symphysis, with a little eversion, if necessary, 
to disengage the head of the bone, and then by inward rotation (Bigelow). 

The possibility of fracturing the neck of the femur during manipu- 
lation must be borne in mind (see Chapter XXVIL). 



CHAPTER XXVI. 

dislocations of the hip. — (Continued.) 

dislocations downward and inward. obturator. perineal, 
dislocations forward and upward. suprapubic. ilio- 
pectineal. dislocations upward. subspinous (bigelow) 
supracotyloid. dislocations downward on the tuberosity 
of the ischium. 

Dislocations Downward and Inward. 

1. Obturator or thyroid dislocations, or dislocations upon the thyroid 
foramen; and 2, perineal dislocations. 

In this class of dislocations the head of the femur leaves the socket at 
its lower, or lower and inner, part, and passes forward and inward to rest 
upon the obturator foramen (obturator dislocation), or passes still further, 
and, crossing the ischio-pubic ramus, projects in the perineum (perineal 
dislocation). The limb is flexed, abducted, and usually rotated outward. 

1. Obturator dislocations. 

These dislocations, although infrequent, are apparently the second in 
order of frequency of those of the hip, and it seems not improbable that 
this form, in part at least, is the first stage in the production of some 
of the suprapubic, and even some of the dorsal dislocations ; that is, the 
head of the bone, having left the socket at its lowest part in forced 
flexion of the limb, may either be turned backward behind the acetabulum 
by adduction, internal rotation, and diminution of the flexion, or forward 
and upward upon the pubis by external rotation and extension; the 
obturator form is produced by its passage more directly forward and 
inward upon the obturator foramen by abduction and external rotation. 

The commonest cause appears to be great violence acting upon the 
back of the pelvis while the limb is flexed and abducted, as in the fall 
of a heavy object upon the back of a man who is stooping forward with 
his legs separated. Simple abduction of the extended limb is apparently 
sufficient to produce the injury, as is shown by a case reported by 
Corne, 1 in which the thigh of a drunken soldier was forcibly abducted 
by his comrades. In a case reported by Keate, 2 and another by Barker, 3 
the mechanism was apparently the same ; in the former the patient, 
while riding, fell into a ditch, his horse falling upon him and widely 
separating his legs ; the head of the femur lay close to the tuber ischii. 
In the latter the patient fell from a height of about thirty feet, striking 

1 Corne : Recueil de Mem. de Med. Mil., Feb. 1867, quoted by Lossen. 

2 Keate : Lond. Med. Gaz., vol. x. p. 19, quoted by Bigelow. 

3 Barker: Amer. Journ. Med. ScL, 1854, vol. xxvii. p. 412. 



DISLOCATIONS DOWNWAKD AND INWARD. 429 

upon a sandbank and having his legs widely separated; both thighs were 
dislocated, and the head of one femur was thought, on rectal examina- 
tion, to have passed through the obturator membrane into the interior of 
the pelvis ; reduction was effected after several unsuccessful attempts 
under ether. 

In another set of cases it is difficult to determine whether the cause 
has been direct impulsion of the head of the femur downward and inward 
by a force acting on the outer side of the great trochanter, or whether it 
has been exaggerated abduction by pressure forward of the outer part of 
the pelvis, as in a case reported by Treub, 1 in which a man while lying on 
his face was run over by a wagon, the wheels passing obliquely across his 
left hip at the level of the trochanter and the pelvis from left to right, 
and received a dislocation of the left hip. 

Pathology, — The reported autopsies in recent cases are very few. 
Verhaeghe 2 examined the body of a patient who died five days after having 
received multiple injuries in a fall, one of which was an obturator dislo- 
cation and had been reduced previous to death, and found the position 
which had been occupied by the head marked by an extravasation of 
blood between the obturator externus and the pectineus, both of which 
were much bruised. The capsule was torn on its inner side, and the 
ligamentum teres was ruptured. In a case examined by Schinzinger, 3 
the patient having died on the day following the accident, the condition 
of the parts was almost identical, but the obturator externus and pec- 
tineus were in part reduced to pulp ; the rent in the capsule occupied its 
inner and lower part, was two inches long, and was prolonged upon the 
anterior face of the neck. 

Curling 4 reported an autopsy in a case in which death followed three 
days after the injury. The patient was a muscular man thirty-eight 
years old, who had been knocked down by a beam. Spontaneous reduc- 
tion took place while he was being turned in bed. The upper part of 
the adductor magnus and lower border of the obturator externus were 
much ecchymosed. "There was a large rent in the front aspect of the 
capsular ligament, which passed from above downward in a direct line 
from the ilio-pectineal eminence to the upper border of the obturator 
externus, the ligament being for this extent torn from its pelvic attach- 
ment." When the dislocation was reproduced the head of the femur 
" pushed the belly of the obturator externus muscle before it, rendering 
it tense and bulging," and the pyriformis and glutei muscles were put on 
the stretch. The ligamentum teres was ruptured close to the femur. 

Duboue 5 examined the body of a man who had been killed by the fall 
upon him of a heavy block of stone which struck against his left side, 
broke several ribs, produced a dislocation of the left hip, and fractured 
the pelvis at the junction of the ilium and pubis, but without displace- 
ment. The head of the femur rested upon the ischio-pubic branch of 

i Treub : Centralblatt fur Chirurgie, 1882, p. 729. 

2 Verhaeghe: G-azette des Hopitaux, 1851, p. 283. 

3 Schinzinger: Wiener med. Presse, 1880, No. 3, quoted by Poinsot. 

4 Curling: Med. Times and Gazette, 1853, ii. p. 423. 

5 Duboue : Bull, de la Societe Anatomique, 1858, p. 496. 



430 



DISLOCATIONS OF THE HIP. 



the pelvis, rather below than upon the obturator externus. The femoral 
vein was ruptured. 

Annandale 1 reported the case of a strong, healthy man, nineteen years 
old, who had been severely injured on a railway, receiving compound 
fractures of the right leg and left forearm and hand, a comminuted fracture 
of the right arm, and a thyroid dislocation of the left hip. "The symp- 
toms of the dislocation were well marked, and consisted of slight flexion 
of the thigh and abduction of the whole limb, which was fixed in this 
position." The dislocation was easily reduced by manipulation; the 
patient died two hours after admission to the hospital. " There was 
slight extravasation of blood among the muscles on the anterior, outer, 
and posterior aspects of the joint; and extravasation of blood and 
severe bruising and laceration of muscles on the inner aspect of the 
joint, more particularly of the fibres of the obturator internus (sic), por- 
tions of which had been forced into the acetabulum. The tendon of this 
muscle was not ruptured. The head of the femur lay in the acetabulum, 
and the capsular ligament was extensively torn on its inner and lower 
aspect, as is shown in Fig. 137, a, 6, <?, d, being the edges of the torn 



Fig. 137. 



Fig. 138. 





Annandale's case of obturator dislocation, show- 
ing rent in the capsule, a, b, c, d ; the head of the 
femur has been returned to the socket, e, the 
ligamentum teres. 



Stanski's case of old obturator dislocation. 
(Malgaigne.) 



capsule. The round ligament, e, was completely torn away from the 
head of the femur, and attached to it was a thin layer of articular cartilage, 
and some small particles of bone. The anterior and a greater part of 
the posterior portion of the capsular ligament were entire, and a careful 
dissection of "them showed, most distinctly, Professor Bigelow's Y-liga- 
ment uninjured." 

Several specimens of old dislocation have been examined ; those of 
Moreau and Stanski, quoted by Malgaigne, Cooper (loc. cit., p. 50), and 



1 Annandale: British Med. Journ., 1870, i. p. 101. 



DISLOCATIONS DOWNWARD AND INWARD. 



431 



Fig. 130. 



Sedillot. 1 In these the head occupied the foramen ovale more or less 
completely, and a new socket had been formed by the growth of bone 
around it ; in Cooper's case the head was so completely enclosed by this 
new socket that it could not be removed from it without breaking its 
edge, and yet it was freely movable and was covered with articular car- 
tilage. In Stanski's (Fig. 138) the Y-ligament had been completely 
transformed into bone, and the head of the femur lay near the tuberosity 
of the ischium, the limb being much flexed and abducted. In Sedillot's 
the head of the femur was atrophied and irregular, but the limb was so 
serviceable that the patient was a professional soldier, and shared in all 
the campaigns of the army. 

Experiments upon the cadaver corroborate the clinical and post-mortem 
data concerning both the pathology and the mode of production. If the 
dislocation is produced by ab- 
duction of the extended limb the 
rent in the capsule is found to 
lie on the inner side of the joint, 
while, when it is produced by 
abduction and outward rotation 
following flexion, or by trans- 
formation of a primary dorsal 
dislocation, the rent is mainly on 
the under side, and its extension 
in front and upward is effected 
by secondary displacement of the 
head. The Y-ligament, remain- 
ing untorn, keeps the limb 
partly flexed, abducted, and 
everted (Fig. 139), the head of 
the femur rests against the inner 
and under side of the acetabu- 
lum, and is prevented from 
rising by its pressure against 
this part of the bone and by the 
untorn portion of the capsule 
above. 

A case of compound disloca- 
tion has been quoted in Chapter 
XXV. 

In a case reported by Cooke 2 
the shaft of the femur was also 
broken just below the trochanters ; the patient was a boy nine years old, 
and the injury was caused by a fall. Probably the dislocation was first 
produced, and then the bone was broken by a continuation of the force, 
or by a second blow. Reduction was easily effected by direct pressure 
on the head, and the patient made a good recovery. 

Symptoms. — The limb is flexed, abducted, and usually rotated outward, 




Obturator dislocation. (Bigelow.) 



1 Sedillot: Gaz. des Hopitaux, 1861, p. 94. 

2 Cooke : Lancet, 1864, i. p. 37. 



432 



DISLOCATIONS OF THE HIP. 



and it appears to be elongated because the foot is projected and brought 
to the ground by a compensatory tilting of the pelvis forward and down- 
ward on the same side (Figs. 140, 141). The trochanteric region is 



Fig. 140. 



Fig. 141. 





Obturator dislocation. (Bigelow.) 



Obturator dislocation. (Bigelow.) 



flattened, and the trochanter lowered and displaced inward ; the adductors 
are usually tense. The outward rotation of the limb is not marked and 
may be absent, or there may even be some inward rotation. 

The statements concerning the comparative length of the limbs on 
measurement are contradictory, presumably because of the failure of some 
observers to place the two limbs in symmetrical positions, or because of 
the greater or less abduction and flexion of the limb when measured. 
Thus, in marked flexion and abduction measurement from the anterior 
superior spine of the ilium to the knee or ankle will show shortening of 
the injured limb ; while, if the limb is extended and but slightly abducted 
the measurement may show an actual elongation. 

The head of the femur may be more or less distinctly felt on deep 
pressure over the obturator foramen, and Treub (loc. cit., supra) observed 
that it could be plainly felt through the obturator membrane by the finger 
in the rectum. The same observation was made by Barker in the case 
quoted above, but he thought that the membrane had been ruptured and 
the head of the femur had passed inside the pelvis. 

In a considerable proportion of cases the patients have been able to walk 
quite well immediately after the accident, and some of them have not 
sought advice until after the lapse of several days, even a fortnight. 
Sedillot states that this w T as so in three of the five cases which he had 



DISLOCATIONS DOWNWARD AND INWARD. 



433 



seen, and one of the patients came to him only because he noticed that 
he could not completely adduct the limb. Similar freedom in the use of 
the limb has been noticed in only one other variety of dislocation of 
the hip. that in which the displacement is directly upward ; it is 
important because it may so easily lead the surgeon to overlook the nature 
of the injury. 

The diagnosis of the dislocation and of the variety is made by attention 
to the attitude and fixation of the limb, the impossibility of completely 
extending and adducting it. the elongation in the extended position, the 
depression of the trochanter, and the presence of the head of the femur 
in its new position. 

Treatment. — Bigelow. in his original paper, gives ten procedures for 
reducing thyroid and downward dislocations, which may be grouped as 
four different methods : 1. manipulation ; 2. traction in the axis of the 
flexed and abducted limb : 3. traction outward upon the upper part of 
the thigh ; 4. transformation into a dorsal dislocation, and reduction as 
such In his last paper {Lancet^ 1878. i. p. 861) he seems to prefer the 
last method, adducting the thigh in order to carry the head to the dorsum 
and enlarge the opening in the capsule, and then reducing by flexion and 
forcible lifting of the head toward the socket. 

Fig. 142. 




"Reduction of obturator dislocation by rotation and circumduction inward. (Bigelow.) 

His directions 1 for reducing by manipulation are: ;> Flex the limb 
toward a perpendicular, and abduct it a little to disengage the head of 



1 Bigelow : The Hip, p. 79. 
28 



434 



DISLOCATIONS OF THE HIP. 



the bone ; then rotate the shaft strongly inward, adclueting it, and carrying 
the knee to the floor (Fig. 142). The trochanter is then fixed by the Y-liga- 
ment and the obturator muscle, which serve as a fulcrum. While these are 
wound up and shortened by rotation (Fig. 143), the descending knee pries 
the head upward and outward to the socket. . . . In this manoeuvre 
the action of the ligament may be aided, if necessary, by a towel passed 
round the head of the femur to draw it upward and outward. Rotation 
outward may be substituted for inward rotation." 

The clinical histories show that both inward and outward rotation have 
succeeded, each after the other has failed, and that the former is quite 



Fig. 143. 



Fig. 144. 







MacCormae's case of old obtu- 
rator dislocation of the left hip. 



The same ; showing the mechanism of th< 
manoeuvre. (Bigelow.) 



likely to transform the dislocation into a 
posterior one ; as outward rotation most 
surely prevents this change, surgeons ap- 
pear now to prefer it. The directions given 
by Kocher, 1 and approvingly quoted by the 
German surgeons, are as follows : 

1. Flexion of the thigh to a right angle 
with the pelvis, while preserving the abduc- 
tion and outward rotation in which the limb is found. This leaves all 
parts of the capsule relaxed. 

2. Traction, to make the posterior part of the capsule tense, and to 
bring the head nearer the socket. 

3. Outward rotation, which, acting through the tense posterior portion 
of the capsule and outer branch of the Y-ligament, brings the head upward 
and backward into place. 

Direct pressure or traction outward upon the upper part of the thigh 
has often proved a valuable aid, either by directly moving the head of 
the femur toward the socket or by furnishing a fulcrum by means of 
which the head could be moved in this direction by adducting the knee. 
One of Bigelow's procedures, for example, is to place the patient " in a 

1 Kocher: Volkmann's klin. Vortrage, No. 83. 






UPWARD AND FORWARD, AND INWARD AND FORWARD. 435 

sitting posture with a log, or post, or bedpost between his thighs, and pry 
the head outward over this fulcrum by means of the long shaft of the 
femur." 

Kocher (loc. cit., p. 620) reduced a dislocation of four weeks' standing, 
which had resisted all other methods, by making continuous traction in 
the axis of the limb and combining with it elastic traction laterally on 
the upper part of the thigh. On the morning of the fourth day reduction 
was found quietly to have taken place. 

In a case in which the dislocation had existed for twenty months and 
the disability was great (Fig. 144), MacCormac excised the head and 
trochanter with a good result. The patient was a sailor nineteen years 
old. For details of the case see Chap. XXVII. 

2. Perineal dislocations. 

The recorded cases of this form are not numerous. It is characterized 
by the presence of the head more superficially placed than in the obtu- 
rator variety and displaced to a greater distance from the socket, so as 
even in one case to press upon the urethra and interfere with the voiding 
of the urine. In Taylor's case, quoted above in compound dislocations 
of the hip, page 403, the dislocation was made compound by a rent in 
the integument of the perineum nearly two inches long ; and, possibly, 
Woodward's case, quoted in the same section, may be looked upon as an 
extreme form of this variety. 

The cause appears to be extreme abduction of the limb, and this abduc- 
tion is also a prominent symptom, the thigh being usually found at or 
nearly at a right angle with the body. Probably the capsule is widely 
torn, and thus may be explained the varying attitude of the limb in respect 
of inversion or eversion. In an autopsy reported by Shaw 1 not only was 
the capsule extensively detached at its inner and posterior insertion upon 
the acetabulum, but also the ilio-femoral ligament was partially separated 
from the neck of the femur, and a small rent extended from that point 
into the capsule. 

Varick 2 reports a case of this kind, and speaks of the head as lying in 
the ischio-rectal fossa. 

Theoretically it appears probable that reduction will be most readily 
effected by traction in the axis of the abducted limb and by direct pressure 
upon the head of the bone or upon the upper part of the shaft, anaesthesia 
being used to prevent opposition by the muscles. The extensive lacera- 
tion of the capsule and ligaments would probably make purely manipula- 
tive methods ineffective. 

Dislocations Upward and Forward, and Inward and Forward. 

Suprapubic. 

I. Iliopectineal. II. Pubic. III. Intrapelvic. 

In these dislocations the head of the femur comes to rest upon the 
superior ramus of the pubis, either at the iliopectineal eminence above 

1 Shaw : Trans. Path. Soc. London, 1859, vol. x. p. 211. 

2 Yarick : N. Y. Med. Kecord, 1883, vol. xxiv. p. 38. 



436 DISLOCATIONS OF THE HIP. 

and a little to the inner side of its normal position (iliopectineal), or, 
more rarely, nearer the symphysis pubis (pubic). On the one side the 
dislocations merge into the supracotyloid, and on the other into the 
obturator. Many of the iliopectineal, in which the head has remained 
very close to and even a little under the anterior inferior spine of the 
ilium, have been described by their reporters and others under the name 
supracotyloid, and some writers describe the pubic variety as a variety of 
the obturator, or, rather, of a class to which they give the name prce- 
glenoid or dislocations forward and inward. Exceptionally the head 
may pass under or through Poupart's ligament and rest in the iliac fossa, 
the intrapelvic or suprapectineal dislocation. 

The head of the bone may leave the socket at its upper and inner 
part, and in this case it appears probable that the head rests on the ilio- 
pectineal eminence, or it may leave it at a somewhat lower point and 
pass inward and forward toward the symphysis, or it may pass at first 
inward and downward across the obturator foramen while the limb is 
flexed, and then move upward to rest upon the upper and front surface 
of the superior ramus of the pubis as the limb is subsequently lowered. 
It is to be remembered that the upper border of the symphysis pubis is a 
little below the level of the centre of the cotyloid cavity in the upright 
position. 

In correspondence with these differences in the position taken by the 
head are found differences in the mode of production, according as the 
head is moved more directly upward, upon the ilio-pectineal eminence, 
by hyperextension of the limb, or is first turned more directly forward 
by outward rotation and abduction and then, after rupture of the anterior 
and inner part of the capsule, is pressed upward or inward. Of the 
former there are a number of clinical examples in which the limb itself 
has been hyperextended, or, more commonly, the trunk has been 
violently pressed backward. while the limb was fixed ; thus, a man steps 
into a hole and falls backward; another, wrestling, is forcibly bent back- 
ward by his antagonist. Of the latter, outward rotation and abduction, 
the clinical instances are not so clear, but the possibility of the produc- 
tion in this manner has been fully proved by experiment upon the 
cadaver ; a muscular woman, 1 carrying a keg of potatoes on her back, 
stumbled and, to avoid a fall forward, threw her body with a twisting 
movement backward; a man 2 while swimming made a vigorous thrust 
with his legs and felt a sharp pain in the groin ; he was still able to 
walk, though with much difficulty, and on examination a dislocation upon 
the pubis was found. 

Pathology. — The pathology has been shown by several autopsies in 
recent and old cases. Aubry 3 found the capsule torn along its anterior 
half near its insertion upon the acetabulum ; the psoas and the crural 
nerve crossed the front of the neck ; the head of the femur lay between 
the psoas and pectineus, raising the latter and the vessels ; there was an 
interval of two centimetres between it and the anterior inferior spinous 

1 Albert: Chirurgie, vol. iv. p. 274. 2 Ure: Lancet, 1857, ii. p. 470. 

3 Aubrey :, Bull, de la Societe de Chirurgie, 1853, vol. lii. p. 377. 



UPWARD AND FORWARD, AND INWARD AND FORWARD. 437 

process of the ilium. Roser 1 found the rent in the front of the capsule 
extending from the anterior inferior spinous process down to the notch ; 
the psoas and iliacus were pushed outward, and the vessels crossed the 
head ; the small external rotators were drawn inward and pressed into 
the acetabulum by the great trochanter. Albert (loc. cit., p. 276) found 
the head resting against the outer side of the ilio-pectineal eminence and 
covered on its inner half by the psoas and iliacus ; when it w T as pressed 
further upward the muscle lay across its neck. The ilio-pectineal fascia 
(the deeper part of the sheath of the vessels) was untorn, but nevertheless 
the artery was displaced outward by the head so that it rested across its 
centre and curved outward immediately below Poupart's ligament ; the 
capsule was torn above and in front for about one-third of its circum- 
ference, the greater part of the ilio-femoral ligament being uninjured ; 
the ligamentum teres was torn away at its insertion upon the head, and 
the cartilaginous rim of the acetabulum was entirely uninjured ; the 
posterior rotators were relaxed. Kocher (loc. cit., p. 616) found the 
capsule torn along its anterior half close to its insertion upon the femur, 
the portion which remained attached to the acetabulum hanging as a flap 
between the head and the socket ; the psoas and iliacus were stretched 
across the neck of the bone, and the vessels lay to the inner side of the 
head ; the ligamentum teres was torn away near its attachment to the 
acetabulum, and the cartilaginous rim of the socket was uninjured. 

In a case reported by Stokes 2 in wdiich the head had passed over the 
brim into the pelvis, the superior ramus of the pubis had been fractured 
and much comminuted. The patient died on the table immediately after 
reduction, by pulmonary embolus, it was thought. 

Two cases in w r hich the dislocation was compound have been quoted in 
Chapter III., p. 39; in one of them the femoral A T ein was ruptured. In 
a case reported by Goldsmith 3 and also quoted in Chapter III., p. 35, 
in which the dislocation had remained unreduced for two months wdien 
the patient came under observation, there was found a diffused pulsating 
swelling occupying the iliac fossa and extending down to the middle of 
the thigh, which had appeared a few days after the accident; the external 
iliac artery was tied, and at the patient's death, five days later, the femoral 
and external iliac arteries were found to be perforated for the distance of 
an inch on their postero-external aspect, and the head of the femur lying 
in the cavity of the aneurism. 

In one or two cases pressure upon the anterior crural nerve has been 
manifested by numbness in its area of distribution. 

A case treated by Bransby Cooper 4 and examined after death at the 
end of three weeks is reported in detail, but it is not clear how much of 
the laceration of the muscles was due to the dislocation and how much to 
the repeated attempts to reduce it, The case is also entirely exceptional 
as regards the rent in the capsule, which is said to have occupied its pos- 
terior portion, " the anterior part, where crossed by the tendons of the 

1 Koser : Arch, fur phys. Heilkiinde, 1857, vol. i. p. 58. 

2 Stokes: Brit. Med .lonrn., 1880, ii. p. 916. 

3 Goldsmith: Amer. Journ. Mod. Sci., July, 1860, p. 30. 

* Cooper: Loc. cit., p. 78, and Guy's Hosp. Reports, 1886, vol. i. p. 82. 



438 DISLOCATIONS OF THE HIP 

psoas and iliacus muscles" being the only part not torn through, and I 
am unable to harmonize this statement with the reported position of the 
head of the femur in the groin on the inner side of the great vessels and 
above the internal circumflex artery. 

In an old case examined by Sir Astley Cooper (loc. cit., p. 71) "the 
head of the thigh bone had torn up Poupart's ligament, so as to penetrate 
between it and the pubes. . . . Upon the pubes a new acetabulum 
is formed for the neck of the thigh bone, the head of the bone beino- above 
the level of the pubes (Fig. 145). . . . The femoral artery and vein 
were placed on its inner side, so that the head of the bone rested between 
the crural sheath and the anterior inferior spinous process of the ilium." 

Fig. 145. 




Old unreduced suprapubic dislocation of the hip. (Cooper.) 

Verneuil, 1 in attempting to make reduction thirty-six hours after the 
accident in a patient eighty-one years old, fractured the neck of the femur. 
Four years later the patient died ; the head was found lying in the notch 
between the anterior inferior spinous process and the ilio-pectineal emi- 
nence, between the psoas and rectus. While in another old case reported 
by Douglas 2 in which there was also a fracture of the neck of the femur 
the head was on the inner side of the vessels ; the history of the case did 
not show when the fracture had been produced. 

Symptoms. — The cases in which the head of the femur lies upon the 
ilio-pectineal eminence appear to be the more common, and this may, 
therefore, be taken as the typical form ; in it the limb is but slightly, if 
at all, abducted, markedly everted, and somewhat shortened (Fig. 146), 
and the head of the femur can be felt more or less distinctly in the groin, 
with the artery pulsating directly in front of it or to its inner side. When 

1 Verneuil : Bull, de la Societe de Chirtirgie, 1870, vol. 11, p. 245. 

2 Douglas: Lond. and Edmb. Month. Journ. Med. Sci., 1848, vol. 3, p. 10G4. 



UPWARD AND FORWARD, AND INWARD AND FORWARD. 439 
Fig. 146. Fig. 147. 





Ilio-pectineal dislocation. "The limb 
is usually a little more advanced and 
abducted." (Bigelow.) 



Suprapubic dislocation. (Bigelow.) 

the head is displaced further toward the 
median line the limb is abducted and flexed 
as well as everted (Fig. 147), and its 
position is more like that of an obturator 
dislocation; the capital difference is the 
position of the head on the pubis where it 
can be distinctly felt and perhaps even seen. The vessels lie on its outer 
side. In both forms the outer and posterior portions of the hip are 
flattened, and the trochanter can be felt covering the cavity of the 
acetabulum. 

Adduction is difficult or impossible ; abduction and flexion usually 
easy. Some patients have been able to walk immediately after the acci- 
dent, but none appear to have done so so freely as some with obturator or 
supracotyloid dislocations. 

These symptoms may be present in varying degrees, and, as in other 
dislocations, may be masked by the tilting of the pelvis. In measuring 
the length of the limb the same care must be taken to place the two limbs 
symmetrically, and this can, as a rule, only be clone by flexing and 
abducting the sound limb ; 
measuring from the anterior superior spinous 

physis pubis. The attitude of the limb is like that found after fracture 
of the neck of the femur, and the differential diagnosis is made by atten- 
tion to the presence of the head in the groin, the flattening of the outer 
aspect of the hip, and the depression of the trochanter. 

Gosselin 1 reported a case in which suppuration near the groin ensued 
a few days after reduction, and death followed on the forty-third day; at 
the autopsy the abscess was found to communicate with the joint through 
the unhealed rent in the capsule. 



distinct shortening will then be found on 
process or from the sym- 



1 Gosselin : Gaz. des Hopitaux, 1853, p. 516. 



410 DISLOCATIONS OF THE HIP. 

In a case reported by Rothe 1 the patient, a girl, fifteen years old, was 
unable to extend the leg upon the thigh three weeks after the accident, 
and the disability was attributed to overflexion of the knee at the time 
the dislocation was received. While pushing a swing forward she tripped, 
fell on her knee, and was then pressed backward to the ground by the 
returning swing. Reduction was made under chloroform by flexion, 
rotation inward, and adduction. 

Of the intrapelvic (Scriba) or suprayjectineal (Bartels) dislocation 
cases have been reported in detail by Scriba, 2 Bartels, 3 and Stokes (above 
quoted). Scriba's patient, a boy thirteen years old, while standing with his 
legs wide apart and the left one thrown back, was struck upon the breast 
and overthrown. The limb was flexed at the knee and hip, adducted and 
rotated inward. The head of the femur lay above the torn Poupart's 
ligament deep in the iliac fossa, and the neck rested on the superior ramus 
of the pubis. The artery, vein, and nerve crossed the head and were 
fully compressed. Slight inward rotation and adduction were the only 
movements possible. During manipulation outward rotation suddenly 
took place and persisted. Reduction was made by lifting the head with 
the fingers until it rested on the ramus, and then bv acute flexion, adduc- 
tion, inward rotation, and finally extension. 

Bartel's patient was a man forty-seven years old who had been thrown 
down by a heavy weight. The limb was shortened about three inches, 
fully extended, parallel to the median line of the body, and widely 
rotated outward. The fold of the groin was obliterated by a diffuse 
swelling extending to the upper limit of the left hypogastrium : the head 
could be distinctly palpated through the abdominal wall, which it slightly 
raised ; the great trochanter was directed backward and could not be felt. 
Flexion was impossible ; inward rotation very limited. 

Treatment. — The rule, of which the application is so general, that in 
attempting reduction the limb should first be placed in the position which 
it occupied when the dislocation occurred, is not suitable to those supra- 
pubic dislocations in which the dislocation takes place while the limb is 
extended. Traction upon the fully extended, abducted, and everted limb 
has indeed been sometimes successful, but it has oftener failed and 
has led to various accidents. The method was early abandoned because 
of the risk of injury to the vessels by overstretching across the projecting 
head of the femur, and flexion was resorted to to diminish this risk and 
to remove what was thought to be the principal obstacle, tension of the 
psoas and iliacus. Of the six procedures given by Bigelow almost all 
include traction upon the flexed thigh and rotation inward ; in some, 
direct pressure downward and outward upon the head of the bone or the 
upper part of the thigh is recommended, and outward rotation is men- 
tioned in one as an equally good substitute for inward rotation. 

Kocher's method is the same as one of those given by Bigelow, and I 
reproduce it here because of its more detailed account of the obstacles to 
be overcome and the means by which the manipulation accomplishes it. 

1 Rothe: Deutsche Klinik, 1868, p. 343. 

2 Scriba : Centralblatt fur Chirurgie, 1879, p. 703. 

3 Bartels: Arch, fur klin. Chir., vol. 16, p. 651. 



DISLOCATIONS DIRECTLY UPWARD. 441 

Flexion relaxes the Y-ligament, but nevertheless by tightening the 
posterior part of the capsule it presses the head more firmly against the 
brim of the pelvis or even pushes it further upward under Poupart's liga- 
ment ; it is therefore necessary that the movement should not be allowed 
to take place upon the head as a centre, but that the head should be 
enabled or forced to descend along the anterior surface of the pelvis as 
the knee is raised before the tightening of the posterior portion of the 
capsule has made this descent impossible. This can be effected by traction 
in the axis of the limb or by direct pressure downward and backward 
upon the head. The steps of the method, then, are : 

1. Traction in the axis of the limb as it lies, in order to bring the 
head over the brim of the pelvis; it is rarely necessary to aid this by 
increasing the extension, abduction and outward rotation of the limb. 
By this means the posterior portion of the capsule is made tense, and its 
point of attachment to the back of the neck of the femur is thereby made 
the centre for the following movements : 

2. Pressure with the hand upon the head of the femur to prevent its 
return upward during flexion. Sometimes this is sufficient to make 
reduction, 

3. Flexion, in order to relax the Y-ligament ; it should not be carried 
to a right angle, otherwise too much strain will be made upon the 
posterior portion of the capsule. 

4. Rotation inward, by which the head is returned to the socket. 

In cases in which the head lies nearer the symphysis abduction of the 
limb during traction is necessary to relax the Y-ligament and the untorn 
portion of the capsule and thus allow the head to approach the acetab- 
ulum ; and in those, possibly rare, cases in which this position is secondary 
to a primary displacement downward and inward (obturator) the flexion 
will be seen to bring the head back to the obturator foramen, and then 
the final steps should be those suitable to that form of dislocation. 

Dislocations Directly Upward. Subspinous (Bigelow). Supra- 

COTYLOIDEA. SUS-COTYLOIDIENNE (Malgaigne). 

Concerning no other class of reported cases of dislocation of the hip 
is the uncertainty as to the nature and extent of the lesion, the point at 
which the head has left the socket, and the mode of production so great as 
in those in which the head is found more or less directly above the socket. 
As has been above said, Blasius grouped under one head — supra-coty- 
loidea — cases in which the head of the femur comes to rest above the 
socket either by secondary displacement forward and upward from a 
primary dorsal (the everted dorsal of the present classification), or by 
secondary displacement backward from a primary suprapubic, or by 
direct dislocation upward, and this grouping, which, while very proper in 
a monograph, seems to me objectionable in a systematic description of 
all the forms, has been accepted and followed by several of the later 
German writers, Albert, Konig, Lossen. Malgaigne included in his six 
alleged examples of displacement directly upward two (Cummins and the 
St. George's Hospital case) which I have placed among the everted dorsal. 
Bigelow groups Malgaigne's variety with those cases in which the head 



442 



DISLOCATIONS OF THE HIP, 



Fig. 148. 



lies further to the inner side (suprapubic), and makes them all a sub- 
variety under the name subspinous. Hamilton makes no formal classifi- 
cation of them, but contents himself with citing a few cases, mainly as 
" anomalous dislocations," some as subspinous, others as supraspinous. 

The incompleteness of many of the descriptions is such that the 
material for a positive opinion upon the character of the displacement is 
lacking, and such cases must, therefore, be passed by without definite 
classification, but there remain a few which sufficiently establish the 
existence of a variety in which the head is displaced directly upward 
toward or a little behind the anterior inferior spinous process of the 
ilium, a variety which presents important peculiarities in the symptoms 
and in the manipulations necessary to effect reduction. Although few in 
number, they are nevertheless numerous and distinct enough to justify 
their recognition as one of the regular dislocations, although a rare one, 
of the joint. 

The cases in which the position of the head of the femur has been 
verified by autopsy are those of Worm aid 1 and Gerdy, 2 and the doubtful 
ones of Cruveilhier, 3 Gely, 4 and Deville. 5 Wormald's patient was a man 
forty years old, who had received his injury at the age of fourteen, by a 

fall from a ladder, and had since had 
good use of the limb. The head of 
the femur lay between the edge of 
the acetabulum and the anterior in- 
ferior spinous process, and was sur- 
rounded by the capsule. The ligam en- 
turn teres was not ruptured. Gerdy's 
patient was caught in a revolving 
shaft, and whirled around by it many 
times ; the injury was supposed to be 
a fracture of the neck of the femur, 
and its true character was only recog- 
nized when reduction took place during 
flexion of the limb. He died on the 
following day. The head of the femur 
lay on the outer third of the upper 
border of the acetabulum, below and 
just outside of the anterior inferior 
spinous process ; the capsule was torn 
along the upper edge of the cavity, 
and the centre of the head was eight 
lines above that of the latter. 

Cruveilhier's specimen was taken from 
the body of an old woman who was sup- 
posed to have a fracture of the neck of 
the femur. The head occupied a new 
cavity formed at the level of the anterior inferior spine, and including 




Gely's case of old supracotyloid dislocation 
(Malgaigne ) 



1 Wormald: London Med. Gazette, 1837, vol. 19, p. 658. 

2 Gerdy, reported by Baron, Gaz. Medicale de Paris, 1838, p. 630. 

3 Cruveilhier: Bull, de la Soc. Anatomique, 1837, p. 164. 

* Gely : Ibid., 1810, p. 303. 5 Deville : Ibid., 1843, p. 264. 



DISLOCATIONS DIRECTLY UPWARD 



443 



Fig. 149. 



the upper part of the old one. The interpretation was disputed by 
Despres, who thought the changes were not of traumatic origin. 

In Gely's (Fig. 148) the injury was received a long time before death ; 
the neck of the bone lay across the anterior inferior spinous process, and 
it was thought the weight of the body in walking was borne by the upper 
part of the capsule reinforced by the tendon of the rectus muscle. 

Deville's specimen was taken from the body of a girl eighteen years 
old. The head of the femur was directly above the acetabulum, in the 
most anterior part of the external iliac fossa, immediately above the 
depression in which the reflected portion of the tendon of the rectus is 
inserted. The capsule was thick and distended, and formed an elongated 
sac, which separated the head from the fossa, and allowed the neck of 
the femur to support, by its aid, the weight of the body. No new cavity 
had formed in the fossa, and the acetabulum was almost completely filled 
with fat. The limb was everted and shortened six centimetres. There 
is reason to think this may have been a secondary 
displacement after a posterior dislocation. 

Of the cases observed clinically those reported 
by Milner 1 and Barker 2 are given in the greatest 
detail and are the most satisfactory. The others 
are the cases of Barrier (quoted by Malgaigne), 
Cock, 3 and Mason", 4 and possibly also one observed 
by Hamilton, another by Allin (quoted by Ham- 
ilton), and a third reported by Tiffany. 5 

Milner's patient was a man twenty years old 
who was thrown down by a horse and fell upon 
his trochanter. There was severe pain in the hip 
for a short time, but he continued at his work 
and did not seek advice until a week later. He 
could then walk with a slight limp and very little 
pain, on the toes of his left foot, the heel when 
he stood upright being about an inch and a half 
from the ground. The legs were parallel to one 
another, and the foot was everted at an angle of 
60°. The left leg was shortened one and one- 
eighth inches. The left hip was absolutely fixed, 
and the attempt to move it caused great pain. 
The left trochanter major w 7 as more prominent 
than the right (Fig. 149) and displaced upward 
and backward, its top being half an inch higher 
than that of the other ; its distance from the an- 
terior superior spinous process was the same as on the other side, the 
elevation compensating for the displacement backward. The distance 
from the centre of the symphysis pubis to the anterior edge of the tro- 
chanter was five-eighths of an inch greater than on the right side. The 




Milner's case of snpracotyloid 
dislocation. 



1 Milner: St. Barth. Hosp. Eep., 1874, vol. 10, p. 316. 

2 Barker : Lancet, 1877, ii. p. 455. 

3 Cock: Guy's Hosp. Reports, 1855, I. p. 282. 

4 Mason: Reported by Hamilton, loc. cit., p. 785. 

5 Tiffany : Maryland Med. Journ., 1883-84, vol. 10, p. 525. 



444 DISLOCATIONS OF THE HIP. 

head of the femur could not be felt, nor was there any swelling to indi- 
cate its presence, except that the femoral artery seemed to be rather 
more superficial on the left than on the right side. There was also a 
slight general fulness in the groin. On turning the patient on his face 
a hollow was observed behind the great trochanter. The distance from 
the spinous processes of the vertebrae (sacral) to the posterior edge of 
the great trochanter was nearly an inch more on the left than on the right 
side. No crepitus could be felt. 

The patient having been put under chloroform, an attempt was made 
by Mr. Savory to reduce the dislocation by manipulation, but it was 
found impossible to ilex the thigh upon the abdomen. After a trial of 
traction by the pulleys, manipulation was again resorted to ; there was 
much more freedom of movement, and when flexion, adduction, and 
rotation outward were made the head of the bone could be distinctly felt 
to move from its position. It seemed as if it worked around the outer 
rim of the acetabulum. This, when the limb was straightened, did away 
with the shortening, but rotation inward was still impossible and the 
prominence of the trochanter remained. On further manipulation the 
bone resumed its former position. This was repeated four times. Trac- 
tion was then made with the thigh flexed at a right angle, and it also 
failed. The attempt was then temporarily abandoned. Eleven days 
later, the patient being again under chloroform, Mr. Savory followed the 
formula of Professor Busch, viz : "Abduct the thigh, rotate it somewhat 
outward, and carry it into hyperextension, then rapidly rotate inward, 
and place it straight." At the second attempt the bone passed noiselessly 
into its place. The patient made a good recovery, although three months 
later he still walked with, a slight limp. 

It was thought that the head of the bone, while displaced, " was below 
and external to the anterior inferior spine of the ilium, resting in the 
hollow between the latter and the projecting rim of the acetabulum, and 
bounded in front and strapped down by the Y-shaped ligament of 
Bigelow." 

Barker's patient was a boy nine years old who, six days before he 
sought advice, had fallen while trying to jump on another's back, his 
right thigh being strongly abducted and somewhat flexed, and his left 
doubled up under him as he fell on his nates. After the fall he felt some 
pain in the hip and his mother noticed the deformity, but he was able to 
walk well. The right thigh was strongly abducted and slightly flexed 
and everted, and was immovable ; the region of the great trochanter was 
flattened, and the fold of the nates obliterated. Two carefully made, 
independent measurements showed shortening of from one-quarter to 
one-half an inch. The adductor longus was very tense. The head of the 
femur could not be felt, but it was clearly not in the thyroid foramen or 
on the pubis. After chloroform had been administered the thigh became 
freely movable, and an attempt was made and repeated to reduce by the 
manipulation commonly used in dorsal dislocations, adduction, flexion, 
circumduction, and outward rotation, but both failed. He then " drew 
the limb gently downward in its long axis, and again adducted, flexed, 
and then circumducted the thigh as before, downward traction being kept 
up all the time on the head, but this time rotated the thigh inivard. 



DISLOCATIONS DIRECTLY UPWARD. 445 

This effort was perfectly successful, but as reduction was effected without 
the slightest start or jerk of the bone as it returned to the socket, the 
fact was not apparent for a moment or two, when I noticed that the limb 
was of its normal length and now lay flat on the table like its fellow. 
The usual prominence of the trochanter was now well marked, as also 
the fold of the nates, and all the motions of the limb were perfectly 
restored. The obliquity of the pelvis had completely disappeared, and 
measurement showed the two limbs now equal in length. The trochanter 
had also come forward again, as indicated by its relation to the apex of 
the well-known triangle drawn with pen and ink before any attempt at 
reduction had been made. After reduction the tip of the trochanter was 
considerably anterior to the apex of the triangle to which it had previously 
corresponded." 

His opinion was "that the head of the femur was forced directly 
upward, and lay just below, and a little outside of, the anterior inferior 
spinous process of the ilium, and immediately above, or upon, the brim 
of the acetabulum." 

Hamilton's case I consider doubtful because the brief description would 
apply equally well to a dislocation downward upon the obturator foramen, 
except for the shortening of half an inch, and that is a point upon which 
the possibility of an error of observation is great ; thus Malgaigne (loc. 
cit., p. 843, note) mentions a case reported by two surgeons, one of whom 
found shortening of half an inch while the other found lengthening to 
the same extent. Hamilton's patient was thrown backward while wrest- 
ling, and on rising found his thigh moderately abducted; he was able to 
walk with a limp. Three years later he jumped from his wagon, felt a 
snap in the joint, and found he could walk without pain or limping and 
could bring his knees together. Three months later, while carrying a 
heavy weight up-stairs, his foot slipped and the dislocation was repro- 
duced. When seen by Hamilton fifteen years later the limb was 
moderately abducted and everted, and all the motions of the joint were 
restricted. 

Of Mason's case it is said the limb was shortened one-quarter of an 
inch, strongly everted, parallel with the other, and slightly flexed. The 
head of the femur could be seen and felt a little below and to the inside 
of the anterior superior (sic) spinous process. The trochanter major was 
turned back, and there was a deep depression over it. The limb could 
be slightly adducted, but in all other respects it was immovable. After 
several ineffectual attempts at reduction under ether it was finally reduced 
by simple extension (traction). As the shortening was so slight I think 
it may properly be assumed that the above is a misprint for anterior 
inferior spinous process, and then the case would closely resemble the 
others, except that the head was on the inner side of the process. 

Similar statements, containing the same possible error, are made by 
Hamilton about Allin's case — namely, shortening of half an inch, and 
the head directly below the anterior superior spinous process. The limb 
was everted, slightly flexed, and nearly parallel with the other ; it could 
be adducted quite freely, but motion in other directions was more limited. 
After the failure of several attempts by manipulation and traction with 



446 DISLOCATIONS OF THE HIP. 

the pulleys the dislocation was finally reduced, after the sudden release 
of forcible traction, by slight flexion and rotation inward. 

These cases seem sufficient to prove the occurrence of a dislocation 
upward in which the head moves but a short distance from its normal 
position and lies close against the upper brim of the acetabulum, resting 
presumably against the untorn tendon of the rectus muscle, and probably 
not associated with much laceration of the capsule, for the persistence of 
the immobility of the limb under anaesthesia indicates a ligamentous 
rather than a muscular cause. In Bigelow's experimental reproduction 
of this form the head of the bone appears always to have been thrown to 
the inner side of the inferior spinous process, and he treats of the variety 
in common with the suprapubic dislocations. The observation of other 
cases in which the head lies to the outer side of the process makes a clear 
distinction between the two forms necessary. 

The diagnosis, as the histories plainly show, is beset with difficulties. 
Some of the patients were able to walk so easily and with so little pain 
after the accident that so serious an injury would not have been sus- 
pected ; and in others the eversion, shortening, and absence of the head 
of the femur from the pubis would very naturally have led, as in some 
cases they did, to the diagnosis of fracture of the neck. An additional 
difficulty lies in the inability in some cases to recognize the position of 
the head of the bone ; these are the ones in which the patient was able 
to walk, and in which, therefore, there would be no probability of fracture, 
and the diagnosis of dislocation would be made on the abduction, eversion, 
shortening, and fixation of the limb. 

The histories throw no clear light upon the mode of production ; the 
Cause has usually been a fall, but the attitude of the leg and the direction 
of the violence are not known. In the cases in which the patients have 
been able to walk immediately after the accident it seems probable that 
the head was displaced by a force acting upon the upper end of the shaft 
to press it forward while the joint was partly flexed. In those cases in 
which the upper part of the capsule is torn in front the head may have 
been forced out by hyperextension. 

Dislocation Downward upon the Tuberosity of the Ischium 
— Infracotyloid. 

In this form of dislocation the head escapes over the lower edge of the 
socket and rests just below it upon the outer surface of the body of the 
ischium. The reported cases are very few, but it seems probable that the 
dislocation is much more frequent as a primary, transitory, one leading to 
either a dorsal or an obturator dislocation, being converted into the former 
by inward rotation and adduction, or into the latter by outward rotation 
and abduction ; and, furthermore, some of the cases have probably been 
reported as obturator dislocations, for the dividing line between them is 
somewhat arbitrary ; thus, Keate's case, referred to above in the paragraph 
on the causes of obturator dislocations, is quoted by Malgaigne as a sub- 
cotyloid dislocation. The form was first described by Bonn in 1800 
(quoted by Lossen), and again by Ollivier. 1 

1 Ollivier: Arch. gen. de Med., 1823, vol. 3, p. 505. 



DOWNWARD UPON TUBEROSITY OF ISCHIUM. 447 

The cause is the same as that of many dorsal and obturator dislocations, 
namely, forcible flexion of the thigh, but exaggerated abduction followed 
by slighter flexion appears also to be capable of producing it. Thus, in 
a case reported by Roux 1 the patient fell with his right leg in a hole; the 
left one remained stretched out on the ground in abduction and was dislo- 
cated ; and Ollivier's patient, a man, seventy-two years old, was knocked 
down by a branch of a falling tree which struck against the lower inner 
part of his right thigh and forcibly abducted it. Pitha (loc. cit., p. 163) 
speaks of a case in which the dislocation was caused by the forcible bending 
of the body backward, but, as Albert points out, not only is his descrip- 
tion of the symptoms unintelligible, but it also does not appear how a 
rent in the lower part of the capsule could be produced in this way. He 
describes the supracotyloid and infracotyloid together as ''vertical dislo- 
cations," and possibly has placed this case in the wrong paragraph. 

The only autopsy is one reported by Luke ; 2 the patient, a man, fifty 
years old, died in consequence of associated injuries : the dislocation, 
which had been easily reduced, was reproduced at the autopsy, and as 
the bone could be made to take no other position it was thought that the 
reproduction was exact. The head of the femur was situated " midway 
between the ischial notch and the thyroid hole, immediately beneath the 
lower border of the acetabulum ; " the gemellus inferior and quadratus 
femoris had been torn, and the ligamentum teres completely detached ; 
the capsule was torn in its lower part. 

Experiment upon the cadaver shows that the Y-ligament remains 
untorn and compels flexion of the thigh upon the pelvis which, however, 
may be masked, as in other forms, by inclination of the pelvis. The 
retention of the head upon the tuberosity is due to the narrowness of the 
rent in the capsule and to the support given by the untorn portions, and 
as the laceration can be easily extended on either 
side the easy transformation into a dorsal or Fig. 160. 

obturator dislocation is intelligible. 

The flexion may be even to a right angle (Fig. 
150), Ollivier's patient was brought to the hos- 
pital seated in a chair ; the limb is more or less 
abducted, and may be slightly inverted or everted. 
Measurement in Ollivier's case, when the other 
thigh was brought into a similar position, showed 
no difference in length, and bv the leno-thenino; 
which has been noted in other cases was probably 
meant only an apparent elongation due to the 
abduction and the consequent inclination of the 
pelvis. The buttock appears rounded and more infracotyloid dislocation. 
prominent, especially when looked at from below (bigelow ) 

when the patient is lying on his back with both 

thighs flexed, and the adductors of the thigh and the flexors of the leg 
are very prominent at the upper part. The great trochanter is further 

1 Knox: Revue Medico-chirurgicale, 1849, vol. 5, p. 364. 

2 Luke : Med. Times and Gaz., 1858, i. p. 12. 




448 DISLOCATIONS OF THE HIP. 

from the crest of the ilium, and the head of the femur can sometimes, but 
rarely, be felt in its new position. 

Movements of the limb are restricted and more or less painful ; flexion 
to a right angle is usually possible, abduction comparatively free, adduc- 
tion limited ; but in Roux's case the thigh could be carried across the 
other one. Both of Gurney's 1 patients could walk fairly well immediately 
after the accident, and Roux's could w T alk a little at first but was soon 
completely disabled by the pain. 

Reduction has always been easy (Roux was unsuccessful on the thirty- 
fifth day with the aid of chloroform) and has usually been effected by 
traction in the axis of the limb, with or without direct pressure upon the 
head of the bone ; sometimes the dislocation has been first transformed 
into a dorsal or obturator and then reduced. 

A suitable method would be: Flexion, if not already present; traction ; 
correction of the existing rotation, if any ; to be aided by direct pressure 
upon the head of the femur from behind. 2 

Dislocation into the pelvis through the fractured floor of the acetab- 
ulum has been described in Fractures, p. 479. A brief reference is 
made by Kronlein 3 to a unique case observed by him in which, by a fall 
upon the feet, the head of each femur was driven through the floor of the 
acetabulum. 

1 Gurney: Lancet, 1845, vol. 3, p. 412. 

2 A paper by Chapplain in the Bulletins de la Societe de Chirurgie, 1874, p. 461, 
containing a detailed report of a case observed b} 7 himself and an analysis of several 
others, may be advantageously consulted by those especially interested in the subject. 

3 Kronlein : Deutsche Chirurgie, Lief. 26, p. 25. 



CHAPTEE XXVII. 

dislocations of the hip. — [Continued.) 

complications. double dislocations. accidents in reduction, 
prognosis and after-treatment. treatment of old disloca- 
tions, congenital dislocations. pathological dislocations. 

Complications of Dislocations of the Hip. 

Among the complications of dislocations of the hip are unusually 
extensive injuries to the soft parts, rupture of, or dangerous pressure 
upon, large nerves and bloodvessels, and fracture of bones. Mention 
has been made of all in connection with the different varieties of dislo- 
cation, and it is necessary only to group and briefly summarize them. 

Rupture or laceration of the muscles about the joint is doubtless 
present in some degree in all cases, and is rarely so extensive as to deserve 
to be looked upon as a complication. In the dorsal dislocations the head 
of the femur may be so far displaced that the gluteus medius, and even 
the gluteus maximus may be in part ruptured, and in the thyroid dislo- 
cations the adductors may be extensively torn from the inferior ramus of 
the pubis and the adjoining part of the ischium, as observed in Taylor's 
compound case above quoted. In the suprapubic form the pectineus 
may be torn, and in the extreme variety known as "intrapelvic," in 
which Poupart's ligament is ruptured, the attached muscles forming the 
anterior wall of the abdomen must also suffer some injury. The exten- 
sion of the bruising and laceration of course increases the shock and 
inflammatory reaction, but calls for no special treatment beyond a more 
rigid and prolonged confinement to bed, and avoidance of movement. 

For compound dislocations see Chapter XXV. 

Rupture or injury of the femoral vessels has been observed only in 
suprapubic and obturator dislocations. The suprapubic ones are those of 
a German military surgeon (CentralbJatt fur Chirurgie, 1880, p. 504) 
and Goldsmith {American Journal Med. Sciences, July, I860,. p. 30), 
both quoted in Chapter III.; the obturator case is that of Duboue {Bull, 
de la Soc. Anatomie, 1858, p. ±96). In the first mentioned the femoral 
vein was torn across and the patient died promptly ; in Goldsmith's an 
aneurism involving the external iliac and femoral arteries formed, and 
was treated two months after the accident by ligature of the external 
iliac ; the patient died. In Duboue's case there was also fracture of the 
pelvis at the junction of the ilium and pubis, but without displacement ; 
the head of the femur rested upon the ischio-pubic branch of the pelvis 
rather below than upon the obturator externus ; the femoral vein was 
torn. The patient died. 

29 



450 DISLOCATIONS OF THE HIP. 

The sciatic nerve in the autopsy of one dorsal dislocation 1 has been 
found stretched across the front of the neck of the femur, and in several 
dislocations produced experimentally upon the cadaver it has been found 
in the same position, but the only recorded instance within my knowledge 
in which symptoms of injury to it have been present is a case reported 
by Jonathan Hutchinson 2 in which the muscles supplied by it were para- 
lyzed and remained so at the time of the report several months after the 
accident. 

In a case of dorsal dislocation reported by Syme 3 the bladder was 
ruptured, but there was also a fracture of the opposite side of the pelvis 
to which this complication is probably to be referred. 

Associated fractures of the head, neck, and shaft of the femur, of the 
rim and floor of the acetabulum, and of different parts of the pelvis have 
been reported. 

Fracture of the head of the femur has been reported in three cases of 
dorsal dislocation. In two of these (Birkett, quoted in Chapter III., 
p. 31, and Moxon, quoted in Chapter XXV., compound dislocations) the 
head was split vertically, and the inner half remained in the cotyloid 
cavity still attached to the ligamentum teres. In the remaining case 
(Riedel, quoted in Chapter III., p. 32) the head and neck were split 
longitudinally, both fragments being displaced from the socket, and the 
upper and posterior portion of the rim of the acetabulum being also 
crushed. 

Fracture of the neck of the femur occurring coincidently with the 
dislocation or subsequently during an attempt to reduce has been observed 
a number of times. Wippermann 4 reported one case and collected thir- 
teen others of which he gives abstracts, but his list includes one case 
(ITervez de Cheyoire) which was probably a simple fracture without dis- 
location, and Birkett's, above mentioned, in which the fracture was of 
the head, and does not include a number of other reported cases ; thus, 
Hamilton quotes no less than twelve cases in which fracture was caused 
during an attempt to reduce, and of these Wippermann's paper contains 
only one. The only cases of which I have knowledge in which the neck 
appears certainly to have been broken at the moment of dislocation are 
one reported by Tunnecliff, 5 one by Post 6 in which both hips were 
dislocated, and one by Lossen, 7 and even in the latter the patient was not 
seen by the reporter until six weeks after the accident ; the patient, an 
old man, was standing on a ladder when it fell, he struck upon his feet 
and then, with the injured side, against the underlying ladder, and Lossen 
supposed the dislocation to have been produced by the second blow. 
The dislocation was dorsal. 

Tunnecliff's patient was a man thirty years old who was struck on the 
left shoulder by a falling tree and crushed to the earth, his feet being 



Quain : Medico-Chir. Trans. , 1848, vol. 31, p 337. 

Hutchinson : Med. Times and Gazette, 1866, I. p. 194. 

Syme: London and Edinburgh Monthly Journal, 1843, vol. 3, p. 498. 

Wippermann : Arch, fur klin. Chirurgie, vol. 32, p. 440. 

Tunnecliff: Amer. Journ. Med. Sci., 1868, vol. 56, p. 123. 

Post: N. Y. Med. Record, 1878, vol. 13, p. 366. 

Lossen : Deutsche Chirurgie, Lief. 65, p. 55. 






COMPLICATIONS OF DISLOCATIONS OF HIP. 451 

driven through the ice on which he was standing. As he fell his body 
inclined to the right, and the right trochanter major struck with great 
force on the ice. The surgeons found " dislocation of the right femur 
into the ischiatic notch with fracture. The exact point and line of frac- 
ture they could not determine. The limb was shortened one and a half 
inch. The right knee was inclined to take position toward its fellow and 
above it. The right foot was inverted, and pointed to the ankle of the 
left foot. The limb was quite movable. Rotation, abduction, adduction, 
or even extension could be readily made, and with but little pain. 
Crepitus was distinctly felt. Luxation was evident, for the head of the 
bone could be distinctly felt in the ischiatic notch, and yet by extension 
the foot could, with facility, be brought down to the side of its fellow, 
and when the force was withdrawn it readily took the position first 
described. The right trochanter was about one and one-half inch above 
the level of the left, and when the limb was rotated while in a quiescent 
state the head of the bone could be distinctly felt rotating in unison with 
it." No attempt to reduce. 

When Dr. Tunnecliff saw the patient a month later he was inclined to 
doubt the existence of a fracture, but felt forced to accept the evidence 
as conclusive. He found "the same shortening and oblique position of 
the limb as described above." On the thirty-eighth day after the acci- 
dent reduction was effected by free manipulation to break up the adhesions, 
followed by flexion and abduction with direct pressure on the head ; the 
bone returned to the socket with an audible snap, but as crepitus was 
felt it was thought that the union of the fracture had been destroyed. 
Five weeks later the patient " could walk with one crutch, and measure- 
ment showed but half an inch shortening of the limb. He has progressed 
favorably since that time/' 

Post's patient was a girl thirteen years old who, six months before 
admission, had received a blow upon the back with "a twisting of the 
body to the right and the lower extremities to the left." Both hips were 
dislocated, and there was also fracture of the neck of the left femur, the 
head of which had become necrosed ; a sinus communicated with it as it 
lay on the dorsum ilii. The head was removed through an incision, and 
the limb straightened. The right dislocation was reduced by manipulation, 
and the patient became able to walk with crutches, the function of the 
right limb being fully restored, the left being shortened four and one-half 
inches. 

Two cases in which the neck of the femur was broken during; an 
attempt to reduce while the dislocation was still recent may be considered 
in connection with the preceding ; they are Verneuil's, quoted in the 
preceding chapter, and Lisfranc's. In both the dislocation was supra- 
pubic. Verneuil's patient was eighty-one years old, and the fracture 
took place while he was flexing, abducting, and rotating inward with only 
moderate force ; union failed. 

Lisfranc's case is quoted by Wippermann ; the patient was seventy 
years old ; the head of the femur lay on the superior ramus of the pubis, 
pressing the artery inward and somewhat raising it. Reduction was 
attempted by traction by ten assistants; " suddenly a crack was heard in 



452 DISLOCATIONS OF THE HIP. 

the joint, the tumor in the groin disappeared (?), and the positive signs 
of a fracture of the neck of the femur appeared." 

Possibly reduction might be effected by direct pressure upon the head 
under anaesthesia, as was done in Cooke's case of obturator dislocation 
with fracture below the trochanter, and I think it should be tried ; if it 
fails, the practice followed in TunneclifFs case seems judicious ; to await 
consolidation, and then to attempt reduction. The alternatives would be 
to seek a pseudarthrosis at the seat of fracture, or to correct the flexion 
and adduction of the limb (in a dorsal dislocation), and seek union with a 
view to the formation of a new socket for the head on the ilium. 

Necrosis of the head followed in one case of coincident fracture (Post), 
and in two cases of fracture during an attempt to reduce an old dislocation 
(Czerny, reported by Wippermann, and Bryck 1 ), and it seems that the same 
complication would be more likely to follow in either of the two last- 
named alternatives than in the plan followed in Tunnecliff's case, for the 
vitality of the head would be preserved, if at all, only through the integ- 
rity of the vessels in the untorn portion of periosteum uniting it with the 
shaft, and the correction of the attitude of the limb, or the manipulations 
necessary to secure a pseudarthrosis might easily obstruct these vessels, 
or rupture the remaining strip of periosteum. 

Fracture of the shaft of the femur, occurring coincidently with its 
dislocation, has been observed a few times. Hamilton collected four cases, 
those of Bloxham, 1833, Thornhill, 1836, Eteve, 1838, and Markoe, 
1853, in all of which it is claimed that reduction was effected. He rejects 
Thornhill's claim as "altogether incredible," and doubts if a dislocation 
existed in Markoe's. In Bloxham 's and Eteve's the fracture was near 
the middle of the shaft, in Thornhill's in its upper third, and in Markoe's 
the site is not mentioned. In Bloxham 's the dislocation was on the 
pubis, and was reduced on the seventh or eighth day by traction with 
pulleys, the limb having been secured with splints, and by direct pressure 
on the head of the bone. In Eteve's the dislocation was backward, and 
reduction was effected by making slight traction upon the upper part of 
the flexed thigh, and by direct pressure on the head of the bone. 

To these may be added Cooke's case of obturator dislocation with 
fracture just below the trochanter, quoted in Chapter XXVI., Cooper's 
of dorsal dislocation with fracture at the middle of the shaft, and Dela- 
garde's of backward dislocation with double fracture of the shaft. Cooke's 
patient was nine years old, and reduction was easily effected by direct 
pressure on the head. Cooper's 2 patient was a lad sixteen or eighteen 
years old; "as the reduction of the hip was, of course, impracticable," 
union of the fracture was alone sought at first, and after five weeks, the 
bone appearing tolerably firm, careful extension by pulleys was made for 
half an hour, and was successful. He also quotes (loc. cit., p. 41) another 
case in which reduction was not made. 

In Delagarde's 3 case the dislocation was backward, and the shaft was 
broken in two places. The dislocation remained unreduced, and the head 
was subsequently excised. 

1 Bryck: Archiv fur klin. Chirurgie, 1873, vol. 15, p. 279. 

2 Cooper: Dis. and Fracts., Amer. ed., 1844, p. 40 

3 Delagarde: St. Baith. Hoep. Keports, 1866, vol. 2, p. 183. 






COMPLICATIONS OF DISLOCATIONS OF HIP. 453 

It would certainly be injudicious, and probably ineffectual, to attempt 
to reduce by traction, but it seems advisable to try direct pressure upon 
the upper fragment, under anaesthesia, in recent cases, rather than to 
await consolidation of the fracture, and during the attempt the limb should 
be placed in the position in which, if the bone were unbroken, the Y-liga- 
ment would be relaxed, for it is probable that the upper fragment will 
share in the movements of the limb. 

For fractures of the floor and brim of the acetabulum, see Fractures, 
pp. 479 and 486. 

Associated fracture of the pelvis, usually of the rami of the pubis and 
ischium, and sometimes extending into the acetabulum, has been reported. 
It has always been caused by great violence acting directly upon the 
patient, and has usually been combined with other injuries which have 
proved fatal. Illustrative cases have been quoted in the preceding 
chapters. In Stokes's case of suprapubic (intrapelvic) dislocation, in 
which the superior ramus of the pubis was broken, the patient died upon 
the table after reduction, in consequence, it was thought, of pulmonary 
embolism. 

Detachment of the labrum cartilagineum. — Zinner 1 reports a case of 
dorsal dislocation complicated by a double vertical fracture of the pelvis 
extending from the pectineal eminence through the margin of the ace- 
tabulum to the tuber ischii and through the inner border of the inferior 
ramus of the pubis, and by detachment of the labrum cartilagineum ; the 
latter was entirely torn away, with the exception of a small piece at its 
upper outer part, and, with its ends twisted about each other, was wedged 
between the outer margin of the acetabulum and the neck of the femur 
and prevented reduction. The ligamentum teres was torn from the ace- 
tabulum and remained attached to the head of the femur and to the 
labrum. 

Simultaneous dislocation of both hips has been reported in twenty 
cases (see Chapter XXV.). Usually the dislocation is not the same on 
both sides, but if backward upon the ilium in one it is forward upon the 
obturator foramen or upon the pubis in the other. The common cause is 
a heavy blow received upon the back or side while the patient is bending 
forward, by which he is twisted to one side, so that one thigh is abducted 
and the other adducted. Of this mode of production Boisnot's 2 case is a 
good example: a bale of goods fell upon a powerful man, forty years old, 
striking him upon the left side of the head and neck, and bending him to 
the right, and caused a dorsal dislocation on the left side, and a supra- 
pubic one on the right. In Barker's case, quoted in Chapter XXVL, 
both dislocations were obturator, and were caused by a fall from a height 
of about thirty feet upon a sand bank, the patient striking upon his feet, 
and having them widely separated. In Schinzinger's 3 case, dorsal on one 
side, and suprapubic on the other, it was thought the latter might have 
been caused by the efforts of the bystanders to drag the patient from 
under the bank of earth that had fallen upon him. 

1 Zinner: Zeitschrift fur Heilkunde, vol. 8, p. 121 ; abstract in Centralblatt fur 
Chir , 1888, p. 55. 

2 Boisnot: Am. Journ. Med. Sci., Oct. 1867, p. 396. 

3 Schinzinger: Wiener med Pre-se, 1880, quoted by Kronlein. 



454 DISLOCATIONS OF THE HIP. 

Simultaneous dislocations of the left hip backward and of the right knee 
forward and upward were reported by Brittain, in the London Medical 
Gazette, 1836, vol. xviii. p. 257 ; and of the knee and hip of the same 
side by Hulke, in the British Medical Journal, 1883, ii. p. 1. 

Accidents caused by attempts to reduce. 

Before the use of ether and chloroform to obtain anaesthesia, and the 
general substitution of milder methods in the place of forcible traction by 
pulleys, it was not rare for severe inflammatory reaction, and even sup- 
puration, to follow reduction or the attempt to reduce, or for the patient 
to die in consequence of the shock and exhaustion produced by the efforts 
of the surgeon. Cooper (loc. cit., p. 33) says " there are plenty of cases 
on record of fatal abscesses from violent attempts at the reduction of dislo- 
cated hips." Such consequences are now extremely rare, but, even when 
forcible traction or other violent manipulations have not been employed, 
they must still be expected occasionally to occur as the result in part at 
least of the original traumatism. 

Fracture of the neck or even of the shaft of the femur has been caused 
in a large number of cases by the surgeon in his efforts to reduce, either 
by forcible traction or by manipulation. Although in modern methods 
but little force, comparatively, is applied by the surgeon, yet it must be 
remembered that that force is habitually applied on the long arm of a 
lever of which the neck of the femur is the short arm, and the fracturing 
strain upon the latter is thereby greatly augmented. The fracture, appa- 
rently, takes place more frequently during rotation or abduction than 
during flexion of the limb. In most of the reported cases the account is 
limited to the circumstances attending the fracture, and no mention is 
made of the subsequent course of the case. Of the 14 cases collected by 
Wippermann (vide supra), including also the one in which the fracture 
occurred simultaneously with the dislocation and another in which it 
probably did, the final result is indicated in 9 ; of these consolidation of 
the fracture took place in 3 and failed in 6, and in two of the latter 
(Czerny, Bryck) in both of which the fracture was secondary and through 
the narrow part of the neck an abscess formed from which the necrotic 
head of the femur was subsequently removed. In consideration of the 
last two cases Wippermann advises that excision of the head of the femur 
should be immediately done in cases in which a fracture of the narrow 
part of the neck has been caused in an attempt to reduce an old disloca- 
tion ; if the fracture is at the base of the neck, "extracapsular," he 
thinks union should be sought. 

Fractures produced during moderate manipulation in recent cases 
should be treated in accordance with the considerations affecting the treat- 
ment of simultaneous fracture and dislocation. 

In Stokes's fatal case of suprapubic dislocation, in which death was 
attributed to pulmonary embolus, it is impossible to say whether the fatal 
result was due to the traumatism or to the reduction. If it was due to 
pulmonary embolus the clot must have formed before reduction was 
attempted, and the latter could only have caused its detachment. 

In a case of fresh dorsal dislocation that came under my care in Bellevue 



PROGNOSIS AND AFTER-TREATMENT. 455 

Hospital in 1886, death occurred half an hour after reduction by manipu- 
lation without anaesthesia. The patient was a muscular young man, a 
worker in a brewery, and the dislocation was caused by a fall from a 
wagon. He was brought to the hospital within an hour after the acci- 
dent, and presented marked symptoms of shock — restlessness, sighing, 
cool surface, small pulse. I placed him at once on his face on a table so 
that the injured limb hung down at the end, and immediately reduced 
the dislocation by making slight pressure with the fingers of one hand in 
the ham, while with the other hand the foot was held so as to flex the 
knee at a right angle and rotate the thigh. He was then placed in bed, 
and died quietly half an hour later. An autopsy was not permitted. 

Prognosis and after-treatment. 

The prognosis after reduction in uncomplicated cases is favorable, the 
patients usually regaining good use of the limb. The inflammatory reac- 
tion is usually slight, and other treatment than rest in bed for two or 
three weeks is rarely required. Occasionally there is a tendency to 
recurrence which needs to be combated either by slight permanent trac- 
tion upon the limb or by keeping it in an attitude that is unfavorable to 
recurrence, extension, abduction, and outward rotation after a dorsal 
dislocation. 

If reduction is not made the patient will be permanently crippled to a 
greater or less degree. Usually a new articular socket is formed by bony 
outgrowths about the head which permits some motion, and the principal 
disability is due to the attitude of the limb, to its lack of parallelism with 
the other, and to the necessity of tilting the pelvis and curving the spine 
in order to bring the foot to the ground ; but in a few cases patients have 
also suffered from persistent pain aggravated by use, and even from 
numbness or paralysis due to pressure on a nerve. 

In the dorsal dislocations the attitude of the limb, flexion and adduc- 
tion, adds considerably to the actual shortening, and the patient may be 
unable to walk without crutches or a support attached to the sole of the 
shoe. In unreduced suprapubic, supracotyloid, and obturator dislocations 
the attitude is less faulty and in a number of cases the limb has been very 
serviceable. 

Habitual dislocations. — A considerable number of cases have been 
reported in which the hip could be voluntarily dislocated by muscular 
contraction or by slight pressure upon the foot when the limb was placed 
in a certain attitude, or in which the dislocation recurred involuntarily 
during use of the limb. Perier 1 collected fifteen cases, more or less 
authentic, including one observed by himself and exhibited to the 
Societe de Chirurgie, and Hamilton nine additional ones. In some the 
peculiarity clearly followed a primary traumatic dislocation, in others it 
was the consequence of congenital or acquired alterations in the constit- 
uent parts of the joint. Only the former will be here considered, the 
latter belonging more strictly in the class of spontaneous or pathological 
dislocations. 

1 Perier: Bull, de la Soc. de Chir., 1859 vol. 10, p. 12. 



456 DISLOCATIONS OF THE HIP. 

The two most satisfactory examples are one observed by Bigelow 1 and 
another quoted by him from a report furnished by Dr. E. M. Moore ; 
both were dorsal. In Bigelow's case " the hip was dislocated while the 
legs were crossed, a wagon in which the man was riding having pitched 
into a hole. In a" few hours the hip was reduced by flexion. Eight days 
after the accident, in attempting to walk upon the limb, it was again 
partially luxated, when the patient himself replaced it by pushing against 
it with one hand and pressing with the other against his knee. Since 
that time both luxation and reduction have been comparatively easy, and 
the patient now displaces the head of the bone backward upon the edge 
of the socket by muscular action, and reduces it by throwing the leg out 
sidewise. The luxation is sometimes attended with pain, and the promi- 
nence caused by the head of the luxated bone is sensitive to the touch. 
The displacement is rather a subluxation, and the limb exhibits slight 
flexion, shortening, and inversion." 

Dr. Moore's patient was a soldier, who, while u skirmishing up a hill, 
sprang back suddenly to avoid the gun of a comrade in advance. His 
left foot became entangled, and his weight dislocated his hip. He felt 
the injury, and supposed it out of joint. Some comrades pulled it in. 
He immediately resumed his skirmishing, and marched seven miles, from 
10 A.M. until 6 p.m. He lay clown at night, and went on duty the next 
day, sharp-shooting, crawling all day. He continued this kind of duty 
five days, and returned to camp, when he was immediately put in intrench- 
ments, and worked two days and two nights. Afterward he went on 
picket, and entered the hospital on the sixteenth day after the accident. 
At present he can luxate the hip-joint at any time, and does it by pressing 
the foot on the floor to fix it firmly, contracting the adductors, and throw- 
ing out the pelvis. The head suddenly leaves the acetabulum and goes 
on the dorsum ilii." 

As no autopsy has been reported in any such case, the explanation of 
the peculiarity can only be inferred. It is probable that the rent in the 
capsule is insufficiently repaired, and the edge of the acetabulum lowered 
at the point where the head of the femur escapes. There is no record of 
any attempt made to correct the condition, unless a case reported by 
Bigelow (loc. cit., p. 55) may be included in this class : the patient was a 
woman twenty-seven years old, with a dorsal dislocation, which had been 
reduced by manipulation after it had existed for several months. When 
seen by Bigelow, sixteen days after reduction, the bone had again become 
displaced. " By forcible flexion, abduction, and eversion I brought the 
head of the bone into the socket with a snap, but when the limb was 
again extended a very slight inversion sufficed to reproduce the disloca- 
tion ; in fact, the limb could not be trusted to itself. After the bone had 
thus repeatedly slipped out, the patient was placed in bed on her back, 
and the dislocation again reduced by flexion, abduction, and eversion, 
which brought the flexed thigh and knee down to the mattress on their 
outer side. The knee was then tied to the bedstead in this position -by a 
towel, and the foot secured to the knee of the sound side until the socket 

1 Bigelow: The Hip, p. 112. 



TREATMENT OF OLD, UNREDUCED DISLOCATIONS. 457 

should be excavated by absorption. In two weeks she was allowed to sit 
up, and in two weeks more was discharged well." 

Treatment of Old, Unreduced Dislocations. 

There is the same uncertainty in old dislocations of the hip as in those 
of other joints, as* to the length of time after which reduction should not 
be attempted. Cases have been reported in which reduction has been 
effected after the lapse of many weeks, or even months ; Sir Astley 
Cooper (loc. cit., p. 81) reports a case in which reduction was said to 
have been produced by a fall after the lapse of five years, and Weller 1 
one in which reduction took place accidentally after forty years. In 
Cooper's case, the only evidence of reduction is that a loud crack was 
heard at the time of the fall, and that the patient when met in the street 
a few weeks later, walked without limping. "VYeller 's patient was a negro, 
fifty-five years old, whose hip had become gradually and spontaneously 
displaced backward at the age of fifteen. The shaft of the femur was 
broken in its upper third by a fall, and during treatment (double inclined 
plane) the patient felt something slip at the hip, and could no longer feel 
the head of the bone. It is stated that the patient was so muscular that 
the examination was very difficult. 

Hamilton collected fifteen cases in which it was claimed that reduction 
had been successfully accomplished after the lapse of long periods, and 
shows that but few, if any, of them can be deemed trustworthy ; in a 
number of them the dislocation was clearly not traumatic, and in the 
others the reports are brief and unsatisfactory. Sir Astley Cooper's 
statement that eight weeks was the period after which it would be impru- 
dent to attempt reduction has been taken rather too literally, and the 
sounder judgment is that the question is to be determined by other facts 
than the simple length of time that has elapsed, such as the distance of 
the head from the acetabulum, its mobility, the degree of the inflammatory 
reaction, the usefulness of the limb, and the health or constitution of the 
patient. If the head has been displaced to a considerable distance, if 
the adhesions surrounding it are firm, if the patient's condition is such 
that suppuration is likely to be provoked, the attempt should not be made. 
The reasons which have been elsewhere given when considering the same 
question with reference to other joints are equally applicable to the hip, 
and justify, in my judgment, the preference of an open arthrotomy to 
forcible attempts by traction and manipulation. 

The special measures that have been employed either to effect reduc- 
tion or to improve the functional condition of the limb are subcutaneous 
division of the opposing bands, open arthrotomy, osteotomy or fracture 
of the neck or shaft, and excision of the head or of the head, neck, and 
trochanter. 

The first two, subcutaneous division and open arthrotomy, are appli- 
cable to relatively recent cases which are thought to be not absolutely 
irreducible, to be supplemented in case of failure by excision. The others 

1 Weller: New Orleans Journ. of Med., 1870, vol. 23, p. 731. 



458 DISLOCATIONS OF THE HIP. 

are applicable to older cases, as palliative measures designed to improve 
the position of the limb and make it movable. 

^Subcutaneous division of opposing bands or muscles has been tried in 
one case, unsuccessfully, by Hamilton (loc. cit., p. 799). The dislocation 
was dorsal, of eight months' standing, in a man twenty-eight years old ; 
after having failed to reduce by manipulation and continuous traction for 
a month, with a weight of twenty pounds, Hamilton introduced a long 
narrow knife "just above the trochanter major, carrying its point inward 
until it touched the neck at the base of the trochanter. From this point, 
the edge of the knife being directed toward the head of the bone, I swept 
the point of the knife slowly along until the head was distinctly felt, the 
point touching the neck apparently in its whole length." The limb was 
kept rotated outward and abducted during the cutting, and was felt to 
yield, so that both outward rotation and abduction became more complete. 
The attempts to reduce by manipulation and traction were then repeated, 
but without success. 

Open arthrotomy has been tried in six cases : Volkmann, 1 MacCormac, 2 
Polaillon, 3 McBurney, Quenu, 4 and Severano. 5 Volkmann's, McBur- 
ney's, and Quenu's dislocations were dorsal at the time of operation ; 
Polaillon's and MacCormac's, obturator. Volkmann, MacCormac, 
Quenu, and Severano failed in the attempt, and they resorted to excision 
of the head or below the trochanter; Polaillon succeeded, but his patient 
died of acute septicemia ; McBurney also succeeded, but a sinus persisted, 
and six months later he found the head carious and excised it. 

Volkmann's patient was a man fifty-one years of age, who was admitted 
to the hospital six weeks after the accident which had caused the dislo- 
cation, obturator. An attempt to reduce by manipulation under anaes- 
thesia, transformed the dislocation into a dorsal one, and a repetition only 
carried the bone back to its original position. This change was made 
several times, and the head was finally left upon the dorsum. Traction 
was then maintained for six weeks, but did no good. A longitudinal 
incision was made May 15, 1876, at the level of the great trochanter, 
with transverse section of the gluteus maximus for a distance of eight 
centimetres. This exposed the head and neck freely, but did not disclose 
the obstacle to reduction ; successive division of the muscles attached to 
the great trochanter was then made, but still reduction was impossible. 
The head of the femur was then turned out through the wound, and a 
layer of muscle, at least one centimetre thick, was seen overlying the 
cotyloid cavity, and firmly adherent to its rim. Sub-trochanteric excision 
was done, and the limb brought into a suitable position. The wound 
healed without incident, and two months after the operation the patient, 
while lying in bed, was able to lift the limb. Nine months later he was 
able to go about without crutch or cane ; he limped, and there was short- 
ening of four centimetres ; flexion w r as possible, and abduction to 25° ; 
rotation and adduction were very limited. 

1 Volkmann: Reported by Rauke in Berlin, klin. Wochenschrift, 1877, p. 357. 

2 MacCormac : St. Thomas's Hosp. Keports, 1879, vol. 9, p. 103. 

3 Polaillon : Bull, de la Soc. de Chirurgie, 1883, p. 101. 
* Quenu : Revue de Ohirurgie, 1887, p. 310. 

5 Severano : Quoted by Trelat, Gaz. des Hop., April 9, 1887. 



TREATMENT OF OLD, UNREDUCED DISLOCATIONS. 459 



Pig. 151. 



MacCormac's patient was a man nineteen years old with an obturator 
dislocation that had existed for twenty-one months and had resisted 
several attempts to reduce ; one of the earlier ones 
was followed by the formation of an abscess in the 
buttock. When he came under MacCormac's care 
the limb was abducted, rotated outward, and 
markedly flexed (Fig. 151). MacCormac made two 
unsuccessful attempts to reduce and the patient left 
the hospital, but returned a month later asking for 
an operation to relieve the constant pain and 
increasing disability. MacCormac rejected the 
suggestion to make a subcutaneous section of the 
femur because of the depth at which it was placed, 
the probable presence of the femoral vessels and 
crural nerve in front of it, and the possible necrosis 
of the detached head, and determined to try to 
replace the head in the socket after division of the 
capsule and opposing bands through a large incision. 

June 5, 1878, a Y-shaped incision was made, the 
two branches of which were directed toward the 
anterior and posterior superior spines of the ilium, 
respectively, and the straight part ran down to the 
great trochanter ; the soft parts were freely divided, 
and when the cotyloid cavity was reached it was 
found to be so reduced in depth that the head of the 
femur, even if it could have been replaced in it, 
would certainly not have remained there. He 
therefore divided the bone with a chisel just above 

the lesser trochanter, and, after a somewhat difficult dissection, removed 
the upper piece. Even after the excision the flexion of the limb could 
not be entirely corrected, but he abstained from section of the contracted 
muscles, immobilized the limb by a long side splint, and maintained con- 
tinuous traction which ultimately overcame the remaining flexion. 

The wound healed without incident, and seven weeks after the operation 
the patient was able to leave the bed. Passive motion ; faradization. 
By the end of the following November the patient was able to walk 
without aid. The shortening was three inches ; the thigh could be flexed 
45° and completely extended. 

Quenu and Severano resected the head alone, and their patients 
recovered ; in Quenu's case the dislocation had existed for eighty days. 

Polaillon's patient was a man forty-six years old, alcoholic, and of 
weak constitution. A dorsal dislocation had been caused by a fall the 
day 'before his admission. On the following day in an attempt to reduce 
by manipulation the dislocation was transformed into an obturator, and 
after being changed backward and forward several times the head was 
left in the latter position. Two other attempts were made during the 
next fortnight, and after the last one, November 20th, the thigh became 
swollen and tender, but these symptoms abated and there remained at 
the time of the following operation, December 16th, only some painless 
swelling of the hip and tumefaction of the glands in the groin. 




MacCormac's case of old 
obturator dislocation. 



460 DISLOCATIONS OF THE HIP. 

Under "the most minute antiseptic precautions" an incision ten 
centimetres long was made, beginning at the anterior inferior spine of the 
ilium, and carried through the fascia and muscles to the same extent ; 
the great trochanter was found fixed against the cotyloid cavity, and a 
thick layer of fibrous tissue, thought to be the anterior portion of the 
capsule, extended from the upper rim of the acetabulum to the upper 
border of the neck of the femur; this was divided, and the finger 
could then be introduced into the articular cavity. Reduction being 
still impossible, the muscles inserted upon the front of the great 
trochanter were in part detached, and the head and neck separated 
from the soft parts as freely as possible by a blunt elevator. The thigh 
was then flexed upon the abdomen, rotated inward, and extended, by 
which the head of the femur was carried behind the acetabulum, and then 
by traction it was brought into the socket. 

Two days later the parts adjoining the wound were infiltrated with 
fetid gas ; several sutures were removed ; the tissues were gray and had 
the odor of putrefaction ; on the fifth day, December 20th, the patient 
died. 

Dr. McBurney's case has not yet been published ; the patient, about 
seven years old, was admitted to St. Luke's hospital, New York, in 1886, 
with a dorsal dislocation of several months' standing. A longitudinal 
incision was made above and along the great trochanter, and the ilio- 
femoral ligament divided close by its attachment to the femur. Reduction 
was then made. The patient was kept in bed for several months because 
of the persistence of a sinus in the wound ; as the probe disclosed the 
presence of bare bone the sinus was enlarged, and as the head of the 
femur was found to be carious it was excised. Sufficient time has not 
yet elapsed for the ultimate result to become known. 

This showing is far from favorable ; of six cases reduction was accom- 
plished in only two ; and of these two one died of the consequences of 
the operation, and in the other the head of the femur became carious. 
Still, it should be said that in MacCormac's case the length of time that 
had elapsed left no reasonable ground for the hope that the operation could 
be successful, and in Volkmann's case it does not appear that the adherent 
muscle which covered the cotyloid cavity could not have been detached. 
The fatal result in Polaillon's case may perhaps be fairly attributed to 
the repeated violence inflicted in the preceding attempts to reduce, from 
which the tissues had apparently not entirely recovered at the time of 
the operation. The caries of the head which spoiled the result in 
McBurney's case is, I fear, a consequence which may frequently follow 
and which may prove to be the most important objection to undertaking 
the operation. 

Excision of the head, or of the head, neck, and great trochanter has 
been done in nine cases, in eight of which the dislocation was traumatic, 
and in three spontaneous, having occurred in the course of acute articular 
rheumatism or typhoid fever. The traumatic cases are those of Dela- 
garde, 1 Volkmann, MacCormac, Quenu, and Severano, already quoted, 

1 Delagarde: St. Barth. Hosp. Kep., 1866, vol. 2, p. 183. 



TREATMENT OF OLD, UNREDUCED DISLOCATIONS. 461 

and Sydney Jones ; l the spontaneous cases are those of Bruns, 2 Rawdon, 3 
and William Adams. 4 In connection with these may be considered the 
cases of Bryck, Czerny, and Post, above mentioned, in which the head 
of the femur became necrosed after fracture of the neck accompanying 
or following dislocation and was removed ; and it may further be added 
that, according to Kronlein, Roser excised the head of the femur in 1874 
in a case of congenital dislocation. 

Delagarde's patient was a man fifty-one years old, who, five months 
before the operation, had been crushed under a fallen wall, receiving a 
dorsal dislocation of the left hip and fracture of the femur in two places ; 
the fractures had united. The slightest attempt to move the thigh made 
the head of the femur press on the sciatic nerve, producing throughout 
the limb a most peculiar and intolerable numbness. The head was 
deeply lodged in the upper part of the sciatic notch. 

A deep incision was made from the trochanter to the sacrum through 
the gluteus, which laid bare the head and neck of the femur ; the liga- 
mentum teres had been strained, but not broken ; the tendon of the pyri- 
formis passed under the neck. By means of a trephine a hole was made 
in the neck of the femur at its junction with the shaft, and the remaining 
strip of bone on each side was sawn partly through with a narrow saw, 
the division completed with bone forceps, and the head and neck removed. 
The sciatic nerve was laid bare for an inch and a half, it was curiously flat- 
tened and moulded to the head of the femur. The relief was immediate. 
The wound healed in six weeks, and the patient was discharged four 
months after the operation with a serviceable limb. 

Jones's patient was a boy eleven years old with a dorsal dislocation of 
six months' standing. " On Nov. 25, 1879, Mr. Sydney Jones excised 
the head of the femur, corrected the malposition of the limb, and drew 
down the upper end of the shaft to the acetabulum, which was filled up 
with condensed cellular tissue and inflammatory material. Now, five 
years after the excision, the boy has a straight limb an inch shorter than 
the opposite one. He can run, jump, play cricket, and ride a tricycle." 

Volkmann's and MacCormac's cases have been given in detail above ; 
both were obturator, but Volkmann's had been transformed into a dorsal 
dislocation before operation. Quenu's was dorsal. 

Bruns's case was a " double spontaneous or pathological dislocation of 
the hip forward and downward (obturator and perineal)." The patient 
was a boy eight years old, who had suffered two years previously with 
acute articular rheumatism affecting all the joints in turn, but persisting 
after two months only in the hips and knees. The limbs gradually 
became abducted, and large abscesses formed and were opened below the 
groins ; the suppuration persisted for many months. 

Both thighs were abducted at a right angle with the trunk, so that the 
knees and toes looked directly outward. The head of the left femur 
could be distinctly felt resting at the junction of the rami of the pubis 
and ischium ; that of the right femur lay upon the obturator foramen. 

1 Sydney Jones : Lancet, 1884, ii. p. 870. 

2 Bruns : Abstract by Tillmanns, Centralblatt fur Chir., 1879, p. 697. 

3 Rawdon: Liverpool Med. Chir. Journ., 1882, p. 22. 
* Adams : Lancet, 1884, ii. p. 775. 



462 DISLOCATIONS OF THE HIP. 

Both hips were immovable, and the knees could not be extended beyond 
a right angle. Locomotion was possible only upon all fours and sidewise. 

Bruns treated the case by excising the head of the left femur, and 
making a subtrochanteric osteotomy on the right side. 

The excision of the head was done through an incision through the 
adductor muscles in the long axis of the thigh, down upon the head of 
the bone. The detachment of the head from the soft parts could not be 
completely effected, and it had to be removed piecemeal after the neck 
had been sawn through. The position of the limb could not at the time 
be corrected, because of the tension of the contracted muscles, but after 
the wound had almost healed the limb was straightened under anaesthesia 
by the employment of moderate force, although with rupture of the tensor 
vaginae femoris ; the upper end of the femur remained in a position 
corresponding to that of an iliac dislocation. The knee also was straight- 
ened, and continuous traction applied. This forcible straightening was 
followed by suppuration at the place where the muscle had been torn, and 
the pus burrowed all along the back of the thigh down to the knee, 
greatly reducing the patient's strength. 

Five months after the first operation, the abscess having completely 
healed, the second operation, subtrochanteric osteotomy, was done upon 
the right side ; the bone was chiseled through three-fourths of its circum- 
ference, and the remainder broken ; the limb was at once made straight, 
and the knee extended, and continuous traction applied to both limbs. 
The wound healed without incident, and in four weeks the fracture was 
consolidated. 

Three months after the last operation the condition of the patient was 
very satisfactory ; both hips and knees extended, the right hip ankylosed, 
the left quite movable, dislocated upon the ilium, rotated outward, and 
shortened five centimetres. The boy had already learned to stand upright 
and walk quite well with a thick sole on the left foot and a cane. 

Rawdon's patient was a girl eight years old, whose right hip had become 
dislocated backward daring an attack of typhoid fever, which ended about 
two months before she came under observation. Very free painless 
flexion was possible, extension to 135°, abduction and outward rotation 
almost entirely lost. An incision two and a half inches long was made, 
parallel with the shaft of the bone a little behind the trochanter ; 
" reaching the neck, the muscular coverings were dissected off the head, 
cutting upon its rotundity with the thumb pressing back the tissues 
which embraced it, until the head could be turned out, and the neck 
divided with a blunt-pointed metacarpal saw." Antiseptic treatment 
discontinued after six days because of the abundance of the discharge 
and accidental wettings; no fever; wound healed in a month. Con- 
tinuous extension by weight and pulley was begun on the third day, and 
maintained for four weeks; the limb was then found to be " capable of 
all the natural movements, freely and without pain." One inch short- 
ening on measurement. Two months after the operation she could walk 
quite naturally without crutches. 

Adams's patient was a boy eleven years old, with a dorsal dislocation 
that had taken place during a rheumatic fever. He made " a T-shaped 
incision with the long arm two and a half inches in length directly over 



SPONTANEOUS OK PATHOLOGICAL DISLOCATIONS. 465 

the head and neck of the bone, and the small arm one inch in length 
transversely over the head of the bone, which was at once exposed. . . . 
It was found that the capsular ligament had been ruptured, and the torn 
margins of the rent passed on either side of and closely embraced the 
neck of the bone. After dividing the margins of the capsular ligament 
the operator passed his small subcutaneous saw to the neck of the bone, 
and cut through it a little below the margin of the articular cartilage," 
and withdrew the head. There was not much suppuration, and the wound 
was completely healed two months after the operation. A fortnight- 
later the patient walked with crutches, and four months later without 
them. " The limb was perfectly straight, and the movement at the hip- 
joint was free in all directions." 

Subtrochanteric osteotomy has been done, in addition to Bruns's case 
above mentioned, by Van Wahl and Koch. 1 The latter's patient was a 
man forty-one years old, with a dorsal dislocation that had existed for 
twenty months, and in which the flexion was so great that the patient 
could not use the limb in walking. October 3, 1881, a wedge of bone 
was removed from the outer and posterior portion of the femur on a level 
with the lesser trochanter ; the wound healed in two weeks, and the bone 
was then broken under anaesthesia, and the limb placed in a gypsum 
dressing in the position of extension, abduction, and outward rotation. 
The fracture united in three weeks, and it was then found that, owing to 
the intractability of the patient, the position had not been preserved, but 
that the limb was flexed 40°, and equally abducted. The functional 
result was nevertheless good. 

He mentions a case of dislocation twenty-five days old treated by Van 
Wahl in like manner, except that the fracture was made at the time of 
the removal of the wedge, in which the result also was good. 

Subcutaneous fracture of the neck has never, so far as I know, been 
intentionally done to correct a vicious position of the limb, but in a 
number of cases in which it has occurred during an attempt to reduce it 
has been utilized for this purpose and with good results, although, as 
above mentioned, necrosis of the head of the femur has twice ensued. The 
objection to it, and also to subtrochanteric osteotomy is that, unless the 
dislocated head is movable the limb is fixed in the position of extension, 
and while that position is advantageous in walking, it is very inconvenient 
when the patient is sitting. In this respect excision of the head is to be 
preferred. 

Congenital Dislocations. (See Chapter IX.) 

Spontaneous or Pathological Dislocations. 

Almost all the different kinds of spontaneous dislocation have been 
observed at the hip, and many of them with a frequency that has not been 
observed at other joints. The weight of the body in walking is a factor 
of much importance and constantly at work, the effect of which is well 

1 Koch : Berlin, klin Wochenschrift, 1882, vol 19, p. 492. 



464 DISLOCATIONS OF THE HIP. 

shown in three cases reported by Liicke, 1 in which the dislocation followed 
rachitic changes in the shape of the femurs and the spinal column. The 
patients were children who, at birth and during infancy, showed no sign 
of dislocation ; after a time rachitic changes occurred, the displacement 
appeared, and walking became difficult. Liicke found a marked lumbar 
lordosis and anterior curvature of the femurs ; the trochanters were 
displaced far backward, and the dislocation was evident. He thought the 
curvature of the femurs was the primary change, and the lordosis compen- 
satory of it, and that the dislocation was due to changes in the acetabulum 
following the consequent pressure at an unusual point. 

Of similar character are those cases in which the dislocation has taken 
place in a healthy joint in consequence of the prolonged maintenance of 
some exceptional attitude, as in a case reported by Franks 2 of a child 
five years old, who had been confined to the bed for many months by an 
arthritis of the left hip, and had lain upon its left side with the knees 
and hips flexed, and the right hip adducted ; a dorsal dislocation took 
place without pain in the right side. Here the contraction of the muscles 
takes the place of the weight of the body in producing the dislocation 
when the limb is long held in a favorable attitude, and many examples of 
this effect have been reported in cases' in which the joint was the seat of 
an arthritis, as in acute articular rheumatism, or in continued fevers, 
typhoid, scarlatina, in which usually there are indications of inflamma- 
tion of the joint, although in some cases attention was first called to the 
joint by the appearance of the deformity. As the individual usually lies 
with the thigh flexed and adducted, the dislocation almost always takes 
place backward and upward ; but in a case observed by Stromeyer, 3 a 
man eighteen years old, affected with acute articular rheumatism, especi- 
ally of the hip, during the entire course of which he had lain on his side, 
the dislocation was into the obturator foramen. 

It is believed that in these cases, at least in those in which there is 
any inflammation of the joint, the quantity of synovial liquid is increased, 
the ligaments and the capsule are softened and, perhaps, lengthened, and 
thus the dislocation is favored. The immediate cause of the dislocation 
is the persistent contraction of the muscles which connect the femur with 
the trunk, a contraction which is stimulated by the pain in th3 joint. 

"Paralytic" or "myopathic" dislocations of the hip, those in which 
the displacement is effected by the unopposed contraction of certain 
muscles or groups of muscles, whose antagonists are paralyzed, have been 
most frequently seen as a consequence of infantile paralysis. As has 
been shown in Chapter X. they were formerly confounded with congenital 
dislocations, and were first clearly separated from them by Verneuil, 4 and 
afterward studied in detail by some of his pupils, especially Reclus. 5 
When the paralysis involves all the muscles of the hip the joint becomes 
loose, and the femur may be displaced and replaced at will, but when 

1 Liicke: Quoted by Forgue and Maubrac, Luxations pathologiques, Paris, 1886, 
p. 15. 

2 Franks : Lancet, 1883, ii. p. 15. 

3 Stromeyer: Handbuch der Chir., 1844, vol. i., quoted by Forgue and Maubrac. 

4 Verneuil : Bull, de la Societe de Chirurijie, 1866. 

5 Reclus: Revue de Med. et Chir., 1878, p. 176. 



SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS. ±65 

only a part of the muscles are paralyzed the contraction of the others 
leads to a permanent displacement. If the posterior muscles are para- 
lyzed, and the adductors remain in good condition, the dislocation is 
dorsal ; if the adductors are paralyzed and the glutei remain sound, the 
dislocation is forward upon the pubis. One of the cases observed by 
Reclus may be taken as a good example of one form ; a child, which had 
previously been healthy and well-formed, was attacked at the age of seven 
years with high fever and a paralysis which, at first general, became 
localized in the glutei and the other pelvi-trochanteric muscles; the other 
groups, especially the adductors of the thigh, recovered their activity ; a 
well-marked dorsal dislocation followed. 

In a case reported by Bradford, 1 a girl, eighteen months old, the right 
thigh was flexed and abducted at a right angle, the adductors were para- 
lvzed, the glutei and tensor vagina? femoris sound. The head of the femur 
eould be felt in the groin upon the superior ramus of the pubis midway 
between the symphysis and the anterior superior spine of the ilium. 
Reduction was effected, but the limb remained almost powerless. 

The cases should be treated by prompt reduction, if possible, and the 
maintenance of the limb in an attitude that opposes recurrence. 

In three cases reported by Roser 2 in 1885. at the Congress held at 
Strassburg, the paralysis was due to spinal disease : in one of them the 
patient produced the dislocation by swinging his legs forward while walk- 
ing with crutches ; in the other two the dislocation took place in bed 
without appreciable cause. 

The limitation of the paralysis to one group of muscles is to be explained 
by the fact that the adductors are supplied by the obturator nerve, a 
branch of the lumbar plexus, and the posterior muscles by branches of 
the sacral plexus, and that the medullary centres of these nerves are at 
different points in the cord, that of the former being at a higher point than 
the other, probably at the upper part of the lumbar enlargement. 

Dislocations due to destruction of the bony parts of the joint by tuber- 
cular disease are comparatively common ; their consideration belongs 
rather to the subject of disease of the hip-joint. 

In like manner the consideration of those dislocations which follow 
changes in the bones produced by chronic rheumatism or dry arthritis or 
in ataxia belongs to works upon those subjects. The alterations in the 
shape of the bones, either by atrophy, or by hypertrophy, are so marked 
that reduction or maintenance of reduction is impossible. In dry, or 
deforming, arthritis not only are all the constituent parts of the joint 
involved in the changes, but the muscles also become degenerated : the 
bones are usually hypertrophied by outgrowths at the borders of the 
articular surfaces, they lose their articular cartilage, and become eroded 
at points of contact. The changes in locomotor ataxia are characterized 
by early and rapid atrophy of the head and neck of the femur with 
destruction to a greater or less extent of the rim of the acetabulum. 
Sometimes dislocation takes place abruptly with well-marked and charac- 
teristic symptoms ; in other cases the symptoms are more like those of 

1 Bradford : Boston Med. and Surg:. Journ., 188^, vol. 108, p. 73. 

2 Roser : Quoted by Forgue and Maubrac, loc. eit., p. 43. 

30 



466 DISLOCATIONS OF THE HIP. 

fracture of the neck of the femur, the foot is everted and the trochanter 
raised, but the movements are exceptionally free and may be painless. 

A case of remarkable laxity of the hip-joint, apparently due to syphilis, 
but somewhat resembling that of ataxia, was reported by Defontaine : l 
when the limb was dependent the deformity was not great, but when the 
patient bore his weight upon it the trochanter projected immediately above 
and to the outer side of its normal position, so that there was a deep 
depression between it and the ilium ; on flexion of the thigh the head of 
the femur projected at the outer and posterior part of the buttock. 

1 Defontaine: De la syphilis articulaire, 1882, quoted by Forgue and Maubrac 






CHAPTEE XXVIII. 



DISLOCATIONS OF THE KNEE. 



Anatomy. — The knee-joint may be regarded as composed of two joints, 
of which one is formed by the patella and femur, the other by the femur 
and tibia ; and the latter is composed of two parts, differing somewhat 
from each other, each of which is formed by one of the condyles of the 
femur and the corresponding portion of the upper surface of the tibia. 
The condyles of the femur are separated from each other by the inter- 
condylar notch, and between the condylar surfaces of the tibia is a 
depression which is interrupted in the centre by the spine. 

The ligaments which bind the femur to the tibia and fibula are the 
external and internal lateral, the posterior, and the crucial. The internal 
lateral ligament, long and fiat, extends from the internal tuberosity of 
the femur to the inner side of the shaft of the tibia ; the external lateral, 
more rounded and cord-like, extends from the external tuberosity of the 
femur to the head of the fibula, overlying the tendon of the popliteus 
above and being embraced by the tendon of the biceps below. The short 
external lateral ligament, lying somewhat more deeply and posterior to 
the other, is attached above to the side of the condyle and below to the 
styloid process of the fibula. The posterior ligament is formed in great 
part by an expansion from the tendon of the semi-membranosus and is 
attached above to the upper part of the intercondylar fossa of the femur 
and below to the posterior margin of the head of the tibia. The crucial 
ligaments extend from either side of the intercondylar notch, that from 
the outer side passing forward and downward to the depression in front 
of the spine of the tibia, that from the inner side passing more directly 
backward to the posterior margin of the upper surface of the tibia behind 
the spine. In full extension of the knee these ligaments are made tense, 
but in flexion at a right angle the lateral ones, especially the external 
lateral, are relaxed. 

The semilunar fibro-cartilages are interarticular structures attached to 
the head of the tibia at their outer margins and ends and having free 
smooth surfaces above and below ; they are triangular on vertical section, 
the peripheral border being thick, the central thin ; as they are rings, not 
disks, each leaves the corresponding condylar surface of the tibia uncovered 
at the centre. The internal one is semicircular, and its ends are attached 
in front of and behind the spine of the tibia respectively ; the external 
one is nearly a complete circle, and its ends are attached to the spine of 
the tibia between those of the internal one, its posterior end is also attached 
to the inner condyle of the femur in connection with the posterior crucial 
ligament. The external cartilage is movable upon the tibia, this freedom 
of motion being utilized in the outward rotation of the leg which occurs 



468 DISLOCATIONS OF THE KNEE. 

at the end of extension, while the internal one is more fixed and serves 
mainly to make a more concave surface for articulation with the internal 
condyle of the femur. The anterior borders of the two cartilages are 
connected together by a slight transverse band, the transverse ligament; 
it is sometimes lacking. 

The capsular membrane fills the gaps between the ligaments ; and those 
portions which extend from either side of the patella to the femur and 
tibia in connection with the vasti muscles and the fascia lata are called 
the lateral patellar ligaments. 

The synovial membrane extends well up on the front of the thigh, 
frequently communicating with a bursa under the quadriceps, is reflected 
over both the surfaces of the semilunar cartilages to the margin of the 
tibia, and invests the crucial ligaments by a reflection from the posterior 
wall. Between the tibia and patella it rests upon a mass of fat, forming 
two lateral folds, the alar ligaments, and sending backward from its 
middle another fold, the ligamentum mucosum, which is attached to the 
front of the intercondylar notch. By these folds and the crucial liga- 
ments the joint is divided into three communicating compartments ; in 
some animals and sometimes in man they are completely distinct or com- 
municate with one another only by small openings. 

Functionally, the femoro-tibial joint is a ginglymo-arthrodial, its 
movements being effected by a combination of gliding, rolling, and rota- 
tion of the bones upon each other. In complete extension no rotation is 
possible, but as the knee is flexed rotation appears and increases. 
According to Meyer, 1 whose researches form the basis of much of the 
later formal descriptions of this joint, the amount of possible outward 
rotation varies with the angle of extension, as follows : 

Angle of extension. Extent of outward rotation. 

150° 11° 

120 12 

90 21 

60 31 

The extreme range of flexion and extension in a preparation from 
which the muscles has been removed is 160°, but the range of voluntary 
motion is only 130°. In complete extension the patella rests upon the 
upper part of the trochlear surface of the femur, and as flexion is made 
it moves downward and is gradually turned outward by the increasing 
prominence of the internal condyle, so that at the last it rests by its 
upper and outer facet on the front of the external condyle and by its 
inner facet against the narrow surface of the outer margin of the internal 
condyle. As the movement of extension approaches its limit the tibia 
undergoes slight outward rotation in which the external semilunar carti- 
lage does not participate, that is, the outer condylar surface of the tibia 
moves backward under the fibro-cartilage ; correspondingly, when flexion 
is begun from the position of complete extension it is accompanied by 
inward rotation of the tibia. The limitation of extension is effected by 
the posterior and lateral ligaments, that of flexion by the contact of the 

1 Mayer: Anatomie, 2d ed., p. 138. 



DISLOCATIONS FORWARD. 469 

soft parts of the calf and thigh and of the posterior margin of the semi- 
lunar cartilages with the back of the condvles of the femur. Lateral 
motion and rotation are entirely prevented in full extension by the lateral 
ligaments ; when the knee is flexed at a right angle the rotation of the 
leg is increased by division of the lateral ligaments ; division of the 
crucial ligaments does not effect rotation. 1 Displacement of the tibia 
forward, backward, or to either side is opposed by the lateral and crucial 
ligaments. 

Statistics. — Dislocations of the knee, of the femora-tibial joint, are 
rare, constituting about one per cent, of all cases. They are divided 
according to the direction in which, the tibia is displaced into forward, 
backward, outward, and inward dislocations, and dislocations by rotation. 
Malgaigne made additional groups of intermediate forms. The dislocation 
may be complete or incomplete, simple or compound. A tabulation 
which I made by the aid of the references to periodical literature in the 
Index-Catalogue of the Surgeon General's Library showed that of 114 
traumatic cases the dislocation w T as forward in 52, backward in 34, out- 
ward in 21, inward in 4, " lateral " in 1, and by rotation in 3. In 21 
of them the dislocation was compound; 11 forward, 4 backward, 6 
outward. 

The injury is very rare in childhood, the two youngest patients in my 
list being aged ten and eleven respectively ; it is of exceptional .gravity 
because of the size of the joint, the fact that it is usualh^ caused by great 
violence, and because of the frequency with which it is compound and 
with which the popliteal vessels are injured. Amputation has been 
resorted to in a large proportion of cases. Simultaneous dislocation of 
both knees has been observed in a few cases. 

Dislocations Forward. 

These may be complete or incomplete, simple or compound. The 
complete seem to be very much rarer than the incomplete ; the com- 
pound occur in an exceptionally large proportion, over 21 per cent, in 
the tabulation just given, and the wound is habitually made by rupture 
of the soft parts posteriorly where they are stretched across the projecting 
condyles of the femur in hyperextension of the leg. 

The cause may be either hyperextension of the leg, or violence 
received upon the front of the thigh or the back of the leg near the knee. 
The former appears to be much the more common ; in it the tibia turns 
upon its anterior margin as a centre, putting the posterior, lateral, and 
crucial ligaments upon the stretch, and after their rupture it glides 
forward along the condyles, or the condyles slide backward along it. 
The hyperextension may be produced by a force applied to the back of 
the leg or foot, or, more commonly, by the propulsion of the trunk and 
thigh while the leg is held stationary and upright ; thus, a man running 
down a hill steps into a hole, the leg entering as far as to its upper third, 
and falls forward. The other cause, direct violence, may act while the 
leg is either extended or partly flexed ; a man standing upright was 

1 Horoch : quoted by Albert, Chirurgie, vol. 4, p. 389. 



470 DISLOCATIONS OF THE KNEE. 

struck upon the front of the knee by the arm of a windlass, receiving, 
beside a dislocation of the tibia backward, a fracture of the patella ; a 
very heavy weight fell upon the front of the thigh of a man who was 
standing, or squatting, with the knee bent (Lowe, Madelung). In 
another set of cases, of which I have met with the records of four 
examples, the mode of production is not clear ; the patients were caught 
in rapidly revolving wheels or shafts and whirled around many times, 
the body passing at some part of its course through a narrow space ; in 
three of these cases both knees were dislocated, in two of them one dislo- 
cation being forward, the other backward, and in the third one dislocation 
was forward and the other inward. In a unique case reported to 
Hamilton the patient was sitting on the platform of a freight car with 
his legs extended and his feet resting on the platform of the next one ; 
as the train slowed the cars came together and pushed the head of the 
tibia upward on the femur. 

In a case reported by Cotton 1 the ligaments of the joint had gradually 
grown so weak that the knees bent backward ; as the patient got out of 
bed one morning a compound dislocation, with rupture of the popliteal 
artery, was produced. 

Pathology. — In the incomplete form, that in which the upper articular 
surface of the tibia is still in contact by its posterior portion with the infe- 
rior surface of the condyles, the injury to the ligaments and other soft parts 
appears to be slight; in the only autopsy, one reported by Desormeaux, 2 
the anterior crucial ligament alone was torn, and that only in part. In 
the complete form, on the other hand, the injuries are very extensive ; one 
or both lateral ligaments, one or both crucial, the posterior, and the 
lateral ligaments of the patella are completely ruptured or widely torn. 
The posterior muscles, the biceps, gastrocnemius, popliteus, even the 
soleus and vastus internus are lacerated or divided ; the internal and 
external popliteal nerves may be torn or bruised, the popliteal artery and 
vein ruptured, the skin of the popliteal space torn through. Sometimes 
the ligaments are ruptured, sometimes they are torn from the femur, 
perhaps bringing with them portions of the bone ; the protruding con- 
dyles appear sometimes as if they had been cleaned with a knife. The 
overriding of the tibia and femur may amount to two or even three 
inches ; in Mayo's case (quoted by Cooper, loc. cit., p. 187) it was said 
to be fully four inches. 

The injuries to the popliteal artery are of exceptional interest and 
importance. Its inner and middle coats may be torn completely across 
(Annandale, Cotton, Knichynicki, 3 Lowe, 4 two cases, Vevers, 5 and Stewart 
and Turner, quoted by Spillmann ; in most of them the dislocation was 
compound) ; or, as in a case examined by Malgaigne, there may be 
several small rents at atheromatous, calcareous points. The artery may 
be simply compressed and remain competent to perform its functions 

1 Cotton: Proc. Connecticut Med. Soc, 1880, vol. 2, p. 54. 

3 Desormeaux : Bull, de la Soc. de Chirurgie, 1853, vol. 3, p. 367. 

3 Knichj'nicki : Allg. Wiener med. Zeitung, 1873, vol. 18, p. 255. 

* Lowe: St. Barthol. Hosp. Keports, 1869, vol. 5, p. 80. 

5 Vevers: Lancet, 1869, ii. p. 542. 




DISLOCATIONS FORWAED. 471 

when the pressure is removed (Davis, 1 Hixon 2 ), or it may be so bruised 
that a thrombus will subsequently form (Brittain). The popliteal vein 
appears from the reports to have been less frequently torn, but when 
bruised it also may become occupied by a thrombus. It seems probable 
that in the cases in which gangrene followed the vein as well as the artery 
was injured. The opportunities for direct examination after death or 
amputation have been numerous ; among the reports may be mentioned 
those by Malgaigne, Volkmann, 3 Albert, 4 Birkett, 5 Annandale, 6 Brittain, 7 
Madelung, 8 Spillmann, 9 and Lowe, above quoted. 

Symptoms. — The leg is usually in almost complete extension, and 
when viewed from the side it is seen to lie in a plane more or less anterior 
to that of the thigh, according as 

the dislocation is complete or Fig. 152. 

incomplete ; it may be hyperex- 
tended, or partly flexed, and may 
be rotated in either direction. 
The outlines of the projecting 
condyles Can be seen and felt in 
the popliteal space, and above 
the tibia in front lies the patella, 
more or less horizontal and ireely Hxi 1 condyle of -femur "^ 

movable, and the skin above it Dislocation of the knee forward. (Bryant ) 

shows marked transverse folds; 

the flat articular surface of the tibia can be felt on each side of the liga- 
mentum patellae. In the incomplete form the deformity is less marked, 
and the diagnosis may be difficult if the region is swollen. 

The shortening, which is produced by the overriding of the tibia in 
front of the femur, appears to be at the expense of the latter when viewed 
from in front, and the appearance suggests a fracture above the condyles. 
Posteriorly, the leg appears shortened, and the skin is tightly stretched 
over the condyles. 

The limb may be fixed in its position, or it may be movable in any 
direction, hyperextension, flexion to a right angle, or laterally. 

If the skin is broken the rent is transverse and posterior, and through 
it one or both condyles may project, or the finger can be readily passed 
into the joint. The main vessels and the internal popliteal nerve com- 
monly lie in the intercondylar notch, and may sometimes be plainly 
visible. 

Injury to, or compression of, the artery is shown by the loss of pulsa- 
tion in the arteries of the foot and ankle ; injury to the nerve by loss of 
sensation or numbness, and, later, by changes due to defective nutrition 
of the limb and by pain. 

The course after injury to the artery is well shown in the report of 

1 Davis- Phil. Med. Times, 1876-7, vol. 7, p. 270. 

' 2 Hixon: North Am. Med. Chir. Rev., 1858, vol. 2, p. 76. 

3 Volkmann : Beitrage zur Chir., p. 119. 

* Albert: Wiener med. Presse, 1872. 5 Birkett: Lancet, 1850, ii. p. 703. 

6 Annandale : Lancet, 1881, ii. p. 903. 

7 Brittain: Lond. Med. Gaz., 1836, vol. 18, p. 257. 

8 Madelung: Berlin, klin. Wochenschrift, 1873. 

9 Spillmann: Diet, encyclop. des Sc. Med., art. G-enou, p 600. 



472 DISLOCATIONS OF THE KNEE. 

Annandale's case, that after injury to the nerve in Le Dentu's. 1 Annan- 
dale's patient complained that the foot felt cold, but sensation in the toes 
was normal; the* dislocation was easily reduced, and the patient did well 
for a week ; then it was noticed that the foot was livid and cold. Two 
days later blebs had appeared upon it, and the discoloration had 
advanced upon the leg; three days later the signs of gangrene were 
marked, and the limb was then amputated above the knee. The inner 
and middle coats of the popliteal artery, which were atheromatous, were 
torn about an inch above its bifurcation, and curled inward ; the vessel 
was plugged by a firm clot. 

Le Dentu's patient, a man twenty-seven years old, was caught in the 
belt of machinery and whirled around rapidly, his legs striking each time 
against the ceiling ; he received a complete dislocation forward of the 
right knee, and a complete backward dislocation of the left one ; the 
latter was reduced immediately, the former on the next day. On the 
nineteenth day the patient complained of sharp pain in both legs, and on 
examination an eschar as large as a fifty cent piece was found on the left 
calf, and another over the right tendo Achillis ; the former healed 
promptly, the latter increased, and part of the tendon sloughed. The 
pain became very severe in the right leg, it was neuralgic in character, a 
sensation of numbness with darting pain in the foot and sometimes in 
the leg, recurring especially at night. It persisted until the thirty-fifth 
day, and returned a week later. On the forty-fifth day another eschar 
appeared on the sole of the right foot opposite to the head of the first 
metatarsal bone. Sensation, which had previously been dulled in front, 
was now entirely lost throughout the right leg, except in the region sup- 
plied by the long saphenous nerve. Four days later the pain ceased, and 
the eschars began to heal. Seven months after the accident the patient 
returned to the hospital ; there was considerable atrophy of the right leg, 
loss of power in the muscles that move the foot and toes, and some stiff- 
ness at the ankle. The movements of both knees were normal, and the 
ligaments appeared to have reunited solidly. The patient limped in 
walking, but the limp was due solely to the atrophy of the muscles and 
to the persistence on the outer side of the sole of the right foot' of one of 
the three ulcerations that had appeared upon the foot and heel. The 
trophic troubles were attributed to a neuritis of the popliteal nerves occa- 
sioned by their laceration or bruising at the time of the accident. 

Paralysis of the muscles of the outer side of the leg has been observed 
in three other cases, Brand, Unruh, and Poinsot, 2 in one of which, how- 
ever (Brand), the fibula had been broken at its upper end. 

Of the compound cases, several recovered with good use of the limb ; 
in others, amputation or excision of the joint was done. 

The prognosis is grave in the compound cases and in those in which 
the artery has been injured, and it is not very favorable even in the 
simpler ones. It must be remembered that gangrene may delay 'its appear- 
ance until the second or even the third week, and that even in some 
simple cases which have done well for a week or two suppuration of the 

1 Le Dentu : Bull, de la Soc. de Chirurgie, 1880, p. 591. 

2 Poinsot: Trans, of Hamilton, p. 1142. 



DISLOCATIONS BACKWARD. 473 

joint has ultimately occurred. Even after simple dislocations that have 
done well there is ordinarily some limitation of the movements of the 
joint. 

Treatment. — Reduction is easy by traction and coaptation of the ends 
of the bones ; ordinarily, no more force is required in the traction than 
an assistant can make with his hands. Flexion of the knee to an acute 
angle has proved, successful. The suggestion that the leg should be 
hyperextended, and the head of the tibia then pressed directly downward, 
is a dangerous one, because of the chance of injury to the popliteal vessels. 

The rule of conduct in the presence of compound dislocations, and of 
those in which there is evidence of injury to the popliteal artery, has been 
the subject of recent discussion. Several compound dislocations in which 
the artery was intact have recovered, and even with full subsequent use 
of the joint, and I believe that the conservation of the limb under such 
circumstances should be attempted. Of course, the utmost care is required 
in the dressing ; the joint should be washed and drained, the dislocation 
reduced, and the limb immobilized. 

Whether or not arrest of pulsation in the arteries of the ankle and 
foot, and its failure to return after reduction, is a positive indication for 
amputation, I cannot say. There is, I think, no case on record, in which 
the limb has been preserved under such circumstances, although the 
attempt has been made a number of times. Velpeau thought it was an 
indication for amputation ; Nelaton thought the attempt to save the limb 
might properly be made. Certainly the simple occlusion of the artery 
by rupture or the formation of a clot ought not, in itself, to be sufficient 
to cause gangrene, as the very large number of successful cases of liga- 
tion of the femoral artery have shown ; and it therefore seems probable 
that some additional cause intervenes, such as obliteration or rupture of 
the vein, or injury to the main nerves. Where such associated injuries 
can be shown to exist, as by paralysis and loss of sensation and by oedema 
and venous congestion of the leg and foot, the limb may properly be 
deemed lost. In a considerable number of cases tardy amputation, even 
after the patient's condition had become very low, has been successful in 
saving life, so that I think conservation of the limb, in selected cases, 
may properly be attempted, with the understanding that amputation must 
be promptly done as soon as the early signs of gangrene of the limb 
appear. 

Dislocations Backward. 

They may be complete or incomplete; in the former the head of the 
tibia is displaced backward and upward behind the condyles ; in the latter 
it still remains partly in contact by its upper surface with the condyles. 

The common cause is direct violence received upon the upper end of 
the tibia in front, or upon the lower end of the femur behind, but in some 
cases the application of the force is more indirect, as when the body and 
thigh are forced forward while the leg is held ; thus, a woman hastening 
to escape from a press of wagons in the street, caught her foot deeply 
under a bar which held the leg upright while the thigh was pressed 
forward. In four cases the patients were caught in machinery and 
whirled around ; and in one case a boy, eleven years old, suffered a com- 



474 DISLOCATIONS OF THE KNEE 

pound dislocation by having his leg caught between the spokes of a wagon 
wheel. 

Pathology. — The posterior ligament is torn, and usually one or both of 
the lateral ligaments ; in a case of complete dislocation with rupture of 
the popliteal artery (quoted by Malgaigne loc. cit., p. 945) in which 
Robert resorted to amputation, all the ligaments were intact except for 
two rents, each three centimetres long, in the posterior portion of the 
capsule through which the tibia protruded. It seems likely that the 
crucial ligaments, or at least the posterior one, must also be ruptured. 
The muscles which bound the popliteal space have been reported untorn, 
but widely infiltrated with blood; and in other cases one or both heads 
of the gastrocnemius and the popliteus have been torn. The semilunar 
cartilages may be in part detached or otherwise injured. In a case 
reported by Vast 1 a portion of the tuberosity of the tibia had been torn 
off by the strain upon the ligamentum patellas. The popliteal vessels, 
both artery and vein, are sometimes completely torn across, and some- 
times only the inner and middle coats of the artery are torn, an injury 
the consequences of which may easily be as serious as those of complete 
rupture. This injury is produced by the forcible stretching of the vessels 
across the sharp posterior margin of the head of the tibia. 

The patella may be drawn directly downward so as to lie below its 
normal position, or it may be displaced outward to the side of the condyle. 
In a case reported by Fitzgerald 2 the patella was broken into several 
pieces, and the joint was opened at the end of a fortnight by the sloughing 
of the overlying skin. The injury was caused by the fall of a heavy 
case upon the front of the knee. The joint suppurated, but the patient 
recovered without entire loss of mobility. 

As complications, fracture of the femur above the condyles, Testut, 3 
and fracture of the tibia just beloAv the knee, Adams, 4 have been reported; 
also rupture of the tendon of the quadriceps femoris, Walshman, 5 Lossen. 6 

Symptoms. — The leg is usually hyperextended upon the thigh, the 
antero-posterior diameter of the knee notably increased, the head of the 
tibia placed behind its usual position and, in the complete dislocations, 
also above the level of the lower surface of the condyles of the femur. 
The leg may also be deviated somewhat to either side, and exceptionally 
it may be flexed. The head of the tibia can be felt in the popliteal space, 
and a marked depression exists below the condyles of the femur in front. 
The patella may lie against the front part of the under surface of the 
condyles, or may be displaced to the outer side, or rotated upon its axis, 
Callender. 7 The amount of shortening is slight in the incomplete form ; 
in the complete form it may be one or two inches. 

Pressure upon or rupture of the popliteal artery is manifested by absence 
of pulsation in the posterior tibial and dorsalis pedis arteries, and may 
result in gangrene of the limb. 

1 Vast: Ball, de la Soc. de Chirurgie, 1877, p. b88. 

2 Fitzgerald: Australian Med. Journ., 1882, p. 554. 

3 Testut: Bordeaux Medical, 1874. 

4 Adams : Lancet, 1881, ii. p. 1108. 5 Quoted by Cooper, loc. cit., p. 190. 

6 Lossen: Deutsche Chirurgie, Lief. 65, p. 131. 

7 Callender: Med. Times and Gazette, 1863, i. p. 161. 



DISLOCATIONS BACKWARD. 475 

The diagnosis is not difficult ; and as reduction is usually easy the 
prognosis in simple, uncomplicated cases is good ; but attention should 
always be paid to the presence or absence of pulsation in the distal 
branches of the artery, both before and after reduction. 

In some reported cases in which the dislocation has remained unre- 
duced, the patient has had good use of the limb. Two such are the cases 
of Bagnall-Oakeley 1 and Karewski. 2 The former's patient was a man, 
seventy years old, who had dislocated his left knee at the age of nine 
months ; he had always made full use of the limb, and had earned his 
living as a brickmaker. A false joint had formed between the femur and 
tibia, which permitted 15° of flexion. The foot and leg were normally 
developed; the thigh had an abnormal anterior curvature. The patella 
could not be recognized, and was thought to have become united with the 
femur. The different prominences of the lower end of the femur were 
absolutely subcutaneous and seemed ready to perforate the skin, but there 
was no trace of previous ulceration. 

Karewski's patient was a servant girl, thirty-two years old, whose 
dislocation had existed for more than sixteen years. The right limb 
presented a typical dislocation backward, and when viewed from behind 
looked like a genu recurvatum, while when seen from in front and the 
side the thigh overhung the leg to a certain extent. The muscles of the 
calf were somewhat atrophied ; the nerves and vessels stretched above the 
tibia like tense cords. The growth of the bones had been materially 
affected, the tibia being three centimetres shorter than the other, and 
also thinner ; while the femur was lengthened by three or four centi- 
metres. The overriding of the tibia and femur was four centimetres. 
Flexion and extension were normal, both actively and passively, and 
although there was much lateral mobility the functions of the limb were 
admirably performed. Pain was felt only after exceptional use. 

In Lossen's case, in which reduction was attempted at the end of six 
weeks and failed, the patient finally walked well ; extension was com- 
plete ; flexion to a right angle. The rupture of the external lateral 
ligament resulted in the production of a genu varum. 

Treatment. — Reduction, which is usually easy, has been effected by 
traction with coaptative pressure upon the adjoining ends of the femur 
and tibia and flexion of the knee and hip. In some cases flexion alone 
has been sufficient. In Testut's case, in which the femur was broken 
just above the condyles, reduction was made by traction under anaesthesia. 

Spence 3 successfully treated an irreducible dislocation by open 
arthrotomy. The patient was a man, sixty years old, who had received 
the dislocation March 15, 1876, two days before admission to the hospital. 
After a failure to reduce under anaesthesia, continuous traction with a 
weight of sixteen pounds was made for three days, and then a second 
unsuccessful attempt was made. March 22d, traction with pulleys having 
also failed, the joint was opened by a curved incision below the patella ; 
it was found filled with clots, the internal lateral ligament broken, and 
the posterior part of the internal semilunar cartilage displaced. After 

1 Bagnall-Oakeley: Lancet, 1882, i. p. 53. 

2 Karewski : Arch, fur klin. Chir., 1886, vol. 33, p. 525. 

3 Spence : Lancet, 1876, ii. p. 534. 



476 DISLOCATIONS OF THE KNEE. 

division of the external lateral ligament and the tendons of the hamstring 
muscles, the dislocation was easily reduced. The wound w T as drained 
and dressed antiseptically, the limb placed on a long posterior splint, and 
continuous traction made with a weight of eight pounds. As the lower 
end of the femur tended to project anteriorly, pressure w T as made upon it 
in front. The traction was maintained until June 15th, and when the 
patient was last seen, September 13th, the limb promised to be very 
useful. 

In compound dislocations, and in those complicated by injury to the 
main vessels and nerves, the principles of treatment are the same as in 
dislocations forward. 

Lateral Dislocations. 

Lateral dislocation, more rare than either of the preceding varieties y 
may be outward or inward, complete or incomplete, simple or compound. 
The outward form is more common than the inward. The term sub- 
luxation has been applied to those cases in which the displacement is 
slight. 

A. Outward dislocations. 

Of the complete form of this dislocation Malgaigne could find only 
one recorded case, and that a doubtful one ; but, since the publication of 
his work, von Pitha 1 has reported two cases in which the dislocation was 
nearly, perhaps quite, complete ; and Hughes 2 has since published a 
third. Yon Pitha's first patient was a young woman who, while carrying 
a heavy basket on her back, suddenly doubled up under it. The right 
tibia was so completely dislocated outward that its entire upper articular 
surface stood out free, so that von Pitha could easily lay four fingers 
upon it. The skin was tightly and smoothly stretched over the articular 
surface, and was continuous at a sharp angle with that of the side of the 
thigh ; the edge of the tibia threatened to cut through the tense, thin 
skin, and in like manner the internal condyle of the femur projected 
abruptly over the leg. The patella was displaced outward, and was 
placed obliquely, almost transversely. Reduction was extraordinarily 
easy. The reaction was so slight that the patient left the hospital on the 
next day. 

His second patient was a robust young man who received his injury 
by springing to the sidewalk from an overturning wagon. The appear- 
ance of the limb, when seen immediately after the accident, was the same 
as in the other case, except that, if possible, the edge of the tibia had 
more nearly cut through the tense, white skin. The flat upper surface 
of the tibia stood out so free beside the femur that an ordinary goblet 
could have rested on it. Reduction was easily made, and the intense 
pain at once ceased. The patient refused to remain in hospital, saying 
that he felt able to w T alk, if necessary. 

In Hughes's case the injury was not compound, but the skin was much 

1 Pitha and Billroth : Chirurgie, vol. 4, part 2, B., p. 258. 

2 Hughes : Lancet, 1880, ii. p. 974. 



LATERAL DISLOCATIONS. 477 

stretched. Reduction was easy. The patient had fallen thirty feet and 
died within twenty-four hours. 

In the incomplete form only a part of the head of the tibia, usually all 
the outer half, projects beyond the side of the external condyle of the 
femur. 

The commonest cause is outward flexion of the knee, abduction, pro- 
duced by a fall upon the foot or by the pressure of a heavy weight upon 
the posterior, or by a blow upon the outer, side of the knee ; in the latter 
case the blow is probably received upon the lower end of the femur and 
not upon the tibia. A rarer cause is direct violence acting transversely 
upon the outer side of the lower end of the femur or the inner side of 
the head of the tibia without causing lateral inflection (Annandale). The 
modeof production appears to be rupture of the internal lateral and perhaps 
of the crucial ligaments by abduction of the leg, followed by the lateral 
gliding of the articular surfaces. 

The only reports of direct examination of the injured joint are 
furnished by Hargrave 1 and Bonn, quoted by Malgaigne, and by Wells. 2 
Hargrave's patient died on the fifty-third day, after suppuration of the 
joint; the internal lateral ligament was completely ruptured, the external 
partly torn ; the anterior crucial torn across, the posterior crucial and the 
ligaments of the patella intact. Bonn's was an old unreduced disloca- 
tion ; he says all the ligaments were intact and that the external condyle 
of the femur rested upon the crest of the tibia. In Wells's case a large 
scale of bone was torn from the inner side of the internal condyle, the 
patient died on the fourth day in consequence of gangrene of the limb. 

Instead of being directly outward the displacement may also be some- 
what backward or forward. When compound, the wound has always 
been on the inside. In one compound case, Notta, 3 the popliteal artery 
was ruptured and the patient died after amputation. 

The symptoms are more or less marked in accordance with the degree 
of the displacement ; the internal condyle of the femur projects more or 
less markedly on the inner side, and the outer part of the head of the 
tibia on the outer side : and the greater the displacement the more likely, 
according to Malgaigne, is it that the outer part of the tibia will be 
rotated backward. The displacement outward of the patella shows 
corresponding variations in degree ; it may be simply inclined, so that 
its vertical axis is directed downward and outward, or it may be carried 
to the outer side of the external condyle. 

The leg may be flexed or extended, and is usually aclducted, but may 
be widely abducted (Fig. 153) ; voluntary movements are generally 
impossible. 

The prognosis does not differ materially from that in the two preceding 
forms ; but it is worthy of note that in a case seen six years after the 
accident by Desormeaux (quoted by Spillmann) the leg was permanently 
abducted 45°, presumably the consequence of failure of repair of the 
internal lateral ligament. In another, reported by Morgan, 4 in which the 

1 Hargrave: Dublin Quart. Journ. Med. Sci., 1850, vol. 9, p. 473. 

2 Wells : Am. Journ. Med. Sc, 1832, vol. 10, p. 25. 

3 Notta: Annales Med. des Calvados, 1876, quoted by Poinsot. 
* Morgan: Lancet, 1825-26, vol. 9, p. 843. 



478 



DISLOCATIONS OF THE KNEE. 



dislocation had remained unreduced for three and a half years, the limb 
could be flexed to a right angle but could not be voluntarily extended, 
so that the patient fell whenever the leg became at all bent while he was 
standing upon it. 

Eig. 153. 




Robert's case of dislocation of the knee outward, with abduction. 



In one reported by Dr. W. T. Bull (K Y. Med. Journal, Jan. 1885), 
and shown to the N. Y. Surgical Society three years later (Jan. 1888), 
the recovery was absolutely complete. 

Treatment. — Reduction, generally very easy, is eifected by traction 
and direct coaptative pressure upon the ends of the bones. It is very 
important that the limb should be immobilized for a long time after 
reduction in order that the torn ligaments may solidly reunite. Probably 
it would be well to keep the limb for three or four months in a firm 
dressing which would keep it extended and prevent lateral bending. 
Passive flexion and extension might be systematically employed during 
much of this time if loss of normal mobility were feared. 

In a case reported by Braun 1 of incomplete outward dislocation which 
proved irreducible arthrotomy was done. The patient was a man forty- 
four years old ; the leg was rotated inward and abducted at an angle of 
145° ; the internal condyle of the femur was prominent, and a small 
movable piece of bone could be felt below its inner side. "A curved 
incision eight centimetres long was made parallel to the internal condyle." 
The small piece of bone proved to be the detached internal tuberosity. 
The internal condyle filled the rent in the capsule so closely that only 
after a long search could a small opening be found below it through which 
the tip of the finger could be passed into the joint ; it was slightly 
enlarged with the knife, and then reduction was easily made. The 
patient made a slow recovery, and the joint remained stiff". 

The treatment of compound dislocations and of those in which the 
artery has been torn is the same as in forward dislocations (q. v.). 

1 Braun : Deutsche med. "Wochenschrift, 1882, p. 291. 



LATERAL DISLOCATIONS. 479 

B. Inward dislocations. 

These also may be complete or incomplete, simple or compound. Of 
the complete form there are only two cases on record, Miller and Hoff- 
mann, 1 and Galli, both quoted by Malgaigne. The first was a man twenty- 
eight years old who while getting into a carriage caught his leg between 
the spokes of the wheel and could not free it before the horses started. 
The femur was completely separated from the tibia and projected outward 
and downward, the external condyle presenting through a wound in the 
skin three inches long. Through this wound the joint and the uninjured 
popliteal artery could be seen. Reduction was made at once without 
difficulty ; four months later the wound had closed and the patient walked 
with crutches. A month later he could walk well without aid. 

Galli's patient, a very muscular young man, was thrown from a horse, 
striking upon the right foot with the limb abducted, the knee bent and 
carried at the same time forward and inward. The lower end of the femur 
had almost entirely passed through the soft parts on the outer side ; the 
ligamentum patellae was ruptured. Reduction was made and the patient 
recovered. Two years later he could ride on horseback, but the knee 
was subject to become inflamed and also to frequent displacements which 
had to be guarded against by wearing a brace. 

The causes of the incomplete form are similar to those of the outward 
dislocations : lateral flexion of the knee or a blow upon the outer side of 
the tibia or on the inner side of the condyle of the femur. 

In a case quoted from Cooper by Malgaigne (loc. cit., p. 960) in which 
there was also rotation inward of the tibia, the soft parts covering the 
external condyle of the femur behind and externally had been ruptured. 
The limb was amputated, and dissection showed a large rent in the vastus 
externus immediately above its insertion upon the patella; posteriorly 
the capsule and gastrocnemius were torn ; the lateral and crucial ligaments 
were intact. 

The symptoms of the incomplete form are the projection of the head of 
the tibia on the inner side and of the external condyle of the femur on 
the outer side. The leg may be inclined outward or inward, rotated 
inward, and more or less flexed. 

Reduction appears always to have been effected without much difficulty 
by traction and coaptative pressure ; and the only special feature in the 
prognosis arises from the rupture of the internal lateral ligament, for if 
its repair is not thorough, or if the limb is prematurely used, the leg 
tends to deviate outward (knock-knee) under the weight of the body. It 
would, therefore, be advisable to support the joint for a long time by 
means of a brace. 

Antero-lateral dislocations constituted in Malgaigne's classification 
a separate class of very rare occurrence, the tibia being displaced forward 
and outward. Of the latter form he found only one recorded example 
and that a doubtful one. In the very rare examples of dislocation for- 
ward and inward no special features appear ; and the same may be said 

1 Miller and Hoffman : London Medical Repository, 1825, p. 346. 



480 DISLOCATIONS OF THE KNEE. 

of the equally rare dislocations backward and outward. They may, 
therefore,, be treated as belonging to the forward and backward disloca- 
tions respectively. 

Dislocations by Rotation. 

In this form the dislocation is characterized by a rotation of the leg 
about its longitudinal axis or about a parallel axis passing through the 
centre of one of the condylar surfaces of the tibia ; in the former case 
both condylar surfaces are displaced from their corresponding condyles, 
and the dislocation is said to be complete; in the latter only one of them 
is thus displaced, and the dislocation is said to be incomplete. The 
descriptive terms outward and inward are used, as in normal rotation of 
the leg, according to the direction in which the toes are turned. 

Outward rotation. — The first recorded case is one reported by Dubreuil 
and Martelliere, 1 at the time internes in Malgaigne's service. The patient 
was a woman, who while walking in the street was struck upon the back 
of the leg by the end of a ladder carried upon a cart which was violently 
turned around and dragged a short distance in collision with a runaway 
horse. The woman was knocked down by the blow, her foot caught 
between the rounds of the ladder, and she was dragged a few feet. When 
brought to the hospital, the leg was completely extended and rotated out- 
ward, so that the internal tuberosity was in front, below the trochlea of 
the femur, the external tuberosity and the head of the fibula behind in 
the intercondylar notch. The patella lay upon the outer side of the 
external condyle. There was also a compound fracture of both bones of 
the leg in the middle third. Reduction was easily made two hours after 
the accident by slight traction upon the upper portion of the leg followed 
by inward rotation. Recovery took place, but the joint was not firm, 
and nineteen months after the accident the patient could not take a step 
without crutches. 

By experiment upon the cadaver the reporters found they could repro- 
duce the dislocation by forcible outward rotation of the leg continued 
until the ligaments were felt to yield. The lateral ligaments were then 
found to be ruptured or torn from one or the other insertion ; the capsule, 
the fascia on the outer side, and some muscular bundles were torn, the 
semilunar cartilages loosened or displaced. The crucial ligaments were 
not torn, but lay parallel with each other in the transverse vertical plane 
passing through their upper insertions. In one experiment the tendon 
of the biceps was torn away from the head of the fibula. The tendon of 
the semi-membranosus was wrapped under the internal condyle and pre- 
vented full extension of the leg. 

Sulzenbacher 2 reported another case and repeated and confirmed these 
experiments. His patient was a young Italian laborer, and the disloca- 
tion was caused by forcible outward rotation of the leg followed by 
hyperextension of the knee. The leg was extended, neither abducted 
nor adducted, and so far rotated outward that as the patient lay on his 

1 Dubreuil and Martelliere: Arch. gen. de Med., 1852, vol. 30, pp. 150 and 288. 

2 Sulzenbacher: Wiener medicin. Presse, 1880, vol. 21, p. 272. 



DISLOCATIONS BY ROTATION. 481 

back the outer border of the foot rested on the bed. Besides the rotation 
there was displacement backward and outward of the upper end of the 
tibia. Notwithstanding the swelling there was a distinct projection of 
the condyles, and the soft parts below them were deeply depressible. 
Below the internal condyle was a movable piece of bone as large as a 
bean. The upper end of the tibia could be felt in the hollow of the knee 
projecting backward and outward and so rotated that the outer surface 
and the head of the fibula lay furthest back and the outer articular surface 
could be felt through the soft parts. The inner articular surface lay in 
the depths of the popliteal fossa. The anterior tuberosity of the tibia 
looked outward and had drawn the patella laterally so that it rested 
snugly on the outer surface of the external condyle, its anterior surface 
being directed outward. There was one inch shortening, and the antero- 
posterior diameter of the joint was notably increased. 

Reduction was easily effected by flexing the leg a little, then rotating 
it inward and pressing the head forward, and finally extending. 

There was a tendency during the first fortnight to subluxation backward 
and outward ; a gypsum dressing was worn during the second fortnight, 
and on its removal the tendency had ceased. At the end of six weeks 
the patient could walk with a cane. 

The case differs from the preceding one in the additional backward and 
outward displacement of the rotated leg. 

Experimenting on the cadaver, Sulzenbacher found that by rotating 
the leg outward 45° he got an incomplete dislocation, accompanied by 
the appearance of a small fragment of bone under the internal condyle 
similar to that observed in his case, and that then by hyperextension he 
could make the dislocation complete and exactly like that of his patient. 
The lesions found on dissection differed from those noted by Dubreuil 
and Martelliere in this, that the crucial ligaments were ruptured and the 
external lateral ligament untorn. The small movable piece of bone proved 
to be the part of the internal condyle to which the internal lateral ligament 
was attached. 

In a case reported by Boursier 1 still another variety is shown, the 
rotation taking place about the internal condyle as a centre. The 
patient, while standing with the outer side of his right leg resting against 
the cross-bar of a pair of skids by which he was unloading a large cask, 
was overthrown by the rapid descent of the cask which struck against 
the inner side of the right knee. The pain was very severe, and when 
raised by his companions he was unable to stand. The knee appeared a 
little enlarged transversely ; the external condyle overlapped the corre- 
sponding articular surface of the tibia, forming a rather large, hard, 
rounded prominence. The patella, firmly fixed upon this condyle, was 
placed obliquely, its external border tending to turn forward. The rela- 
tions of the internal condyle and inner surface of the tibia were normal. 
Palpation was painful along the interarticular line, especially at the outer 
side. Voluntary movement was impossible. Passively, flexion could be 
made nearly to a right angle, but was very painful ; the limb could not 

1 Boursier: Journ. de Med. de Bordeaux, 1882-8, vol. 12, p. 225, quoted by 
Poinsot. 

31 



482 DISLOCATIONS OF THE KNEE. 

be completely extended, and there was no rotation. No sign of fracture. 
Reduction was easily made under anaesthesia by slight traction and 
inward rotation of the leg. The patient recovered completely. 

Another case has been reported by Mazel, 1 and Malgaigne quotes the 
accounts of two speciments of old unreduced dislocations given by God- 
man and Petrequin. Of the former it is only said that " the leg has 
undergone complete outward rotation, so that the foot points directly out- 
ward, the heel corresponding to the hollow of the other foot, and the 
articulation of the knee crossing its natural position at right angles." 

Still another variety, displacement forward of the inner side of the 
head, the outer remaining in place, has been recently reported by Henaff.^ 
"A sailor, thirty-three years old, while squatting with his heels together 
and knees abducted and flexed, was struck upon the inner side of the 
head of the left tibia by an iron ring through which a hawser had begun 
to run rapidly. When brought to hospital the leg was partly flexed and 
not deviated to either side ; flexion and extension were limited, abnormal 
lateral movements very free. The relations of the external condyle and 
tibia were unchanged ; the inner side of the head of the tibia was dis- 
placed forward, and the internal condyle was prominent posteriorly. The 
patella was inclined so that its anterior face looked forward and inward, 
its inner border rested on the inner condylar surface of the tibia, and its 
outer border and point raised the skin, the point being nearly in the 
median line. Reduction was easily effected by traction and internal 
rotation, and the patient made a complete recovery. 

Inward rotation. — Of this the only recorded instance is one reported 
by Paris, and quoted by Malgaigne. " The internal condyle of the tibia 
had slipped behind the corresponding condyle of the femur. The limb 
was shortened five or six centimetres, and the leg and thigh formed an 
arc of a circle." Malgaigne supposes this to have been an incomplete 
dislocation by rotation inward, and explains the alleged shortening as 
an error of observation. He mentions in connection with it a singular 
displacement which he had himself seen, and which he thought belonged 
to this class more than to any other. When seen by him it had existed 
five years. Although the patient limped, he flexed and extended the leg 
quite freely. In extension the internal condyle projected very slightly 
forward and inward, and the relations of the external condyle were 
normal. In marked flexion the internal condyle projected considerably 
forward and inward, the inward projection being more than two centi- 
metres, and the external condyle projected slightly forward. 

Dislocation of the Semilunar Cartilages. 

(" Subluxation of the knee." Heys " Internal derangement of the knee.'') 

A certain group of symptoms at the knee, occasioned usually by slight 
violence, such as the twisting of the leg or marked flexion of the joints 
and having a decided tendency to recur, to which attention was first per- 

1 Mazel: Montpellier Medical, 1863, vol. 10, p. 76. 

2 Henaff: These de Paris, 1883, No. 277. 



DISLOCATION OF SEMILUNAR CARTILAGES. 483 

manently called by Hey 1 nearly a hundred years ago, is still far from 
being thoroughly understood. In many cases the symptoms are identical 
with those caused by a floating cartilage in the joint, and many of the 
reported cases, especially the earlier ones, were probably of this character. 
Hey said " The complaint may be brought on, I apprehend, by any such 
alteration in the state of the joint as will prevent the condyles of the os 
femoris from moving truly in the hollow formed by the semilunar car- 
tilages and articular depressions of the tibia. An unequal tension of the 
lateral or cross ligaments, or some slight derangement of the semilunar 
cartilages may probably be sufficient to bring on the complaint." He 
reported five cases, and said he had seen many others ; the difficulty 
always occurred suddenly, sometimes without recognizable cause during 
ordinary use of the limb, the joint becoming " locked'' in the position of 
slight flexion, with more or less pain, the patient being unable to bring 
his heel to the ground and walking on the toes, but the joint could always 
be freely moved passively. It was always relieved by gradual passive 
extension of the limb followed by sudden full flexion. His first case is 
very like one of loose cartilage, and Malgaigne thinks the last two were 
chronic arthritis. 

In 1731 Bassius (quoted by Malgaigne) reported the first case, but it 
differs notably from all that has since been reported, for the external 
semilunar cartilage had become much hypertrophied in consequence of 
an arthritis, and formed a projection on the outer side as large as the 
thumb; it could be pressed into place with crepitation, and became 
displaced when the pressure was removed. 

In some cases a distinct projection has been noticed in front, formed 
by one or the other cartilage, which could be made to disappear by pres- 
sure or by flexing and extending the joint, and with the disappearance 
of the projection the symptoms ceased ; but in Malgaigne 's case it is 
noted that there was a similar, though smaller, projection at the other knee 
without symptoms. It is upon these few cases of recognizable projection 
and upon the sensation sometimes felt of a distinct slipping or jar in the 
joint while it is moved, that the theory of displacement of the cartilage 
rests, it being supposed that it slips forward upon the head of the tibia so 
that its thicker posterior margin lies between the condyle and tibia at or 
in front of the point where they come most nearly into contact or actually 
touch. No post-mortem examination has been made in any case, and 
the only experiments are those of Bonnet. He was able by hyperexten- 
sion of the knee to rupture the posterior attachments of the cartilages, 
but this mode of production is entirely unlike that observed clinically ; 
in one case, in a loose-jointed cadaver, he was able by forced outward 
rotation to engage the internal cartilage in front of the condyle without 
rupture, and, as Malgaigne says, this resembles what is observed in the 
living, except that the leg remained rotated, and the head of the tibia 
projected in front of the condyle. The same effect was obtained in the 
same manner by Dubreuil and Martelliere in their experiments upon 
dislocations by rotation mentioned above. In a case seen by Hamilton 
this subluxation of the inner part of the joint with outward rotation 

1 Hey : Observations in Surgery, Am. ed., 1805, p. 208. 



484 DISLOCATIONS OF THE KNEE. 

appears to have occurred and to have been followed after a few weeks by 
a liability to the occurrence of the symptoms under consideration accom- 
panied by the presence of a small, hard movable lump on the inner side 
of the ligamentum patellae. As the primary accident was followed by a 
sharp arthritis, this lump may have been of inflammatory origin. 

In the chance examination of two knee-joints without history, the 
external semilunar cartilage has been found detached and displaced into 
the centre of the joint; they proved the possibility of this displacement, 
but there was then no reasonable ground for connecting them with the 
clinical cases. The specimens were described by Reid 1 and Godlee ; 2 in 
each the rupture of the attachments had taken place along the periphery 
of the cartilage, and it had lodged vertically in the intercondylar notch 
alongside the spine of the tibia and the posterior crucial ligament. In 
each, the opposing articular cartilage on the condyle and tibia showed 
some roughening. Reid's patient died in hospital, and during his stay 
there had made no complaint of the knee, and had not been observed to 
limp. 

In a case reported by Nicoladoni, 3 a lump was felt in the interarticular 
line in front, and was thought to be a floating cartilage ; on cutting down 
upon it, without having opened the capsule, it proved to be the semilunar 
cartilage, and was drawn back into the interior of the joint during flexion, 
reappearing on extension. 

In another, Fergusson (quoted by Marsh) found in a dissecting-room 
subject "that one of the semilunar cartilages had been torn from the tibia 
throughout its whole length, except at its ends, so that in flexion and 
extension it sometimes slipped behind the articular surfaces. The carti- 
lage was flattened in its outer margin, and when it passed behind the 
condyle of the femur, seemed to fit to the articular surfaces as accurately 
as the internal cavity does in the natural condition of the parts." 

Marsh 4 gives a fourth case : " In a subject lately in the dissecting-room 
of St. Bartholomew's Hospital, a considerable piece had become partially 
detached from the rim of the internal cartilage, and was found standing 
up like a tongue, so that it would have had the effect, when it was nipped 
between the bones (as it was in certain positions of the joint), of locking 
the knee. A deep groove on the cartilaginous edge of the femur had 
been formed by long pressure, for its accommodation." 

In four cases recently reported by Annandale, 5 which he treated by 
arthrotomy, the semilunar cartilage (in three the internal, in one the 
external) was found torn away from its anterior attachment and folded 
back into the cavity of the joint ; he drew it forward into place, and 
made it fast by catgut sutures ; the patients all recovered without accident, 
and were relieved of their disability. The cases were characterized clini- 
cally by the recognizable absence of the cartilage from the edge of the 
tibia in front. 

In most of the cases the symptoms are like those occasioned by a float- 

1 Reid: Edinb. Med. and Surg. Journ., 1834, vol. 42, p. 377. 

3 Godlee: Trans, of Path. Soc, London, 1879-80, voi. 31, p. 240. 

3 Nicoladoni: Arch, fur klin. Chir., 1881-2, vol. 27, p. 667. 

* Marsh : Dis. of Joints, p. 199. 

5 Annandale : Brit. Med. Journal, 1885, i. p. 779, and 1887, i. p. 319. 



DISLOCATION OF SEMILUNAR CARTILAGES. 485 

ing cartilage, and, as has been said, probably some of the reported cases 
are such ; the patient feels that the knee has suddenly become locked, 
with more or less pain and loss of power over the limb, which he can 
neither flex nor extend. Then, after a time, and as the result of manipu- 
lation of the joint or of the limb, he feels that all is right again, and 
walks as well as before. In others the joint has remained stiff and slightly 
flexed for weeks, or even years (Smith's 1 ), and has then been cured by 
pressure with the thumb upon the projecting semilunar cartilage, while 
the limb was repeatedly flexed and extended. In some cases the cartilage, 
usually the internal, can be distinctly felt to project in front; in others 
there was no such recognizable change. In a case described by Lucas, 2 
it is said that when the knee became about half flexed the leg and foot 
jerked inward with a sudden shock, and at the same time a projection 
appeared at the outer side of the patella, and the patient said, "now my 
knee is locked." Flexion could then be completed without any great 
discomfort, and in extension the leg and foot jerked outward when the 
same point was reached, and the cartilage went back into place. 

In a case presented by Lannelongue 3 to the Societe de Chirurgie, a 
girl eleven years old, the external semilunar cartilage was displaced 
forward with a distinct sound, so as to be plainly visible under the 
skin whenever the knee was flexed 20° from full extension, and returned 
to its place with a similar sound when, in extending the limb, it had 
passed about 20° beyond a right angle. This condition had come on 
suddenly about a year previously, and the knee had at last become so 
painful that the child could not walk. 

Le Fort, 4 himself the subject of the affection, felt that something 
became displaced forward in the knee whenever the limb was markedly 
flexed, and returned to its place with a distinct snap and with pain when 
the limb was straightened. On one occasion the displacement appeared 
to be backward ; the pain in straightening the limb was very severe and 
lasted for a week. 

In a case seen by Agnew, 5 a lady while playing with a kitten on the 
floor, suddenly found both knees had become locked, so that she was 
unable to rise. 

As in these last instances, flexion of the knee beyond a certain point 
is, in some cases, sure to produce the condition, and this is then relieved 
by extension ; but in most the occurrence is not so uniform in its mode 
of production, and the commonest cause appears to be a rotation of the 
leg. 

Treatment has almost always yielded good results, both in relieving the 
condition and in preventing recurrence. The manipulations which have 
proved most efficient in the common form, those due to a twist or turn of 
the leg, have been the ones recommended by Hey, extension as far as is 
possible without much pain, and then sudden forcible flexion. When the 
cartilage can be felt to project pressure upon it should be conjointly 

1 Smith : Trans. Clinical Soc. London, 1884, vol 17, p. 123. 

2 Lucas : Brit. Med. Journal, 1879, ii. p. 774. 

3 Lannelongue : Bull, de la Soc. de Chirurgie, 1879, p. 573. 

4 Le Fort : Bull, de la Soc. de Chirurgie, 1879, p. 578. 

5 Agnew : Surgery, vol. 2, p. 114. 



486 



DISLOCATIONS OF THE KNEE 



employed. In such cases as those of Lannelongue and Le Fort, simple 
complete extension was sufficient. 

The after-treatment may require permanent pressure by a pad at the 
point at which the cartilage tends to protrude, or the wearing of a brace 
that will limit the movements of the joint. Marsh, 1 who has treated many 
cases, recommends a clamp (Fig. 154) " which consists of a steel band 
passing across the back of the joint, and ending laterally in two plates, 
which clasp the joint and skirt the edges of the patella, a pad being 



Fig. 154. 



Fig. 155. 




placed beneath the plate, should either of the semilunar cartilages be felt 
to project." For the less amenable cases he recommends the more bulky 
apparatus shown in Fig. 155. Prolonged immobilization of the limb in 
a fixed dressing, has been used in a number of cases and seemed to aid 
in overcoming the tendency to recurrence. Nicoladoni sought to prevent 
the forward movement of the cartilage by drawing together the tissues 
from above and below by buried sutures, to form a sort of pad in front of 
it, but no benefit followed. Annandale operated through a free transverse 
incision along the anterior edge of the head of the tibia, opened the 
capsule, and drew the cartilage forward with a hook. 

Congenital Dislocations. 

Excluding a few cases in which various malformations of the knee have 
been found in foetal monstrosities showing many other abnormalities, and 
one or two doubtful cases, the reported cases of congenital dislocation are 
seventeen in number. 2 In one, Mason, the displacement was backward ; 



1 Marsh: Dis. of Joints, p. 211. 

2 They are those of Kleeberg and Chatelain, quoted by Malgaigne ; Bard, You- 
mans, and Hamilton, 2 cases (Hamilton, loc. cit. , p. 895); Friedleben, Schmidt's 
Jahrbuch, vol. 112, p. 307 ; Motle, quoted by Hibon, These de Paris, 1881, No. 10, 
p. 34 ; Gueniot, 2 cases, Bull, de la Soc. de Chirurgie, 1880, p. 442 ; Perier, idem, p. 
683 ; Bertin, Union Medicale, 1880, vol. 30, p. 616; Richardson and Porter, 2 cases, 
Boston Med. and Surg. Journ., 1875, vol. 93, p. 321 ; Mason, N. Y. Med. Record, 
1877, vol. 12, p. 42 ; Maas, Arch, fur klin. Chirurgie, 1874, vol. 17, p. 492 ; Albert, 
Chirurgie, vol. 4, p. 435. In addition, Albert names four others which I have not 
found : Wutzer, Dubrisay, Godlee, and Barwell. In one reported by Cruveilhier, 
it was claimed" that there was hyperextension without displacement. 



CONGENITAL DISLOCATIONS. 



487 



in one of Hamilton's it was backward at both knees ; in the remaining 
fifteen it was forward, with marked hyper extension of the leg upon the 
thigh, frequently so extreme that the foot lay at the groin. In a few 
cases there is mention of a blow or fall received by the mother while 
carrying the child, but it cannot be maintained that the cause is in any 
case clear. The facility with which the displacement could always be 
reduced, the normal shape of the bones, and the prompt establishment of 
the functions of the limb point toward an accidental mechanical cause ; 
probably, in the movements of the foetus the leg is extended and becomes 
engaged in such a position that it cannot be flexed, and then by the pres- 
sure of the wall of the uterus hyperextension is effected. Hyperexten- 
sion in consequence of unopposed contraction of the quadriceps can 
hardly be supposed, for the flexors have not been found paralyzed. In 
the single case of double backward dislocation, Hamilton, the flexors were 
contracted, and their tendons had to be divided before the legs could be 
straightened. 

Of the 13 cases in which the sex was noted, 10 were females, 3 males ; 
in 4 the right knee was dislocated, in 7 the left, and in 4 both ; in 2 of 
the latter 4, Hamilton, Friedleben, both hips also were dislocated. In 
Maas's the patella was lacking. Friedleben's died during delivery, 
Mason's at the age of one month. The only detail given in Mason's 
case is that the reduction was easy, so that Friedleben's and Albert's are 
the only ones available for the study of the changes ; in Friedleben's the 
articular surface of the tibia rested against the front of the lower end of 
the femur ; the condyles of the femur and the head of the tibia were 
normally developed, the patella normally attached, the capsule loose and 
large. 

In Albert's, a newborn child, both legs were in dorsal flexion at a right 
angle. The articular surface of the femur had the shape shown in Fig. 
156. The upper part of the synovial sac and the ligamentum alare were 
lacking. The inner semilunar cartilage was 
only a narrow strip, the outer one was well 
developed ; the crucial ligaments were very 
broad and long, the inner one being inserted 
further inward on the tibia than normal ; on 
slight outward rotation of the leg the two 
crucial ligaments became parallel to each 
other. The popliteal vessels and nerves lay 
behind the external condyle. 

Of Maas's patient it is said there was no 
difference in the length of the limbs or in the 
development of the muscles, and the same 
absence of inequality is noted in Gueniot's, 
Motte's, and Berlin's. In Kleeberg's the 
limb is said to have been three-fourths of an 
inch shorter than the other in straight ex- 
tension, but the inequality disappeared on 
traction. 

The attitude of the limb at birth, in the forward dislocations, was 
hyperextension to or beyond a right angle, sometimes so extreme that 



Fig. 156. 




Congenital dislocation of the knee. 
(Albert.) 



488 DISLOCATIONS OF THE KNEE. 

the front of the leg was actually in contact with the front of the thigh ; 
usually there was no deviation of the leg to either side. It was always 
freely movable, could be brought down to the position of straight exten- 
sion by moderate force, and in most cases could even be flexed nearly or 
quite as far as usual ; on removal of the pressure the limb resumed the 
position of hyperextension. While the joint was dislocated the condyles 
of the femur projected at the back of the popliteal space, the head of the 
tibia lying against their anterior surface, and the patella situated well up 
on the thigh. In several cases the skin on the front of the knee was 
thrown into transverse folds, in the grooves between which sebaceous 
matter had sometimes collected. Nothing in any case indicated that the 
dislocation was recent and traumatic, and the experiments made by Hibon 
upon the bodies of newborn and stillborn children show that in a similar 
forcible dislocation, even by a force acting continuously for several hours, 
detachment of one or both epiphyses always occurred, with, however, 
but slight separation and not always with rupture of the periosteum. In 
the forcible straightening of the leg the quadriceps became tense, and in 
a few cases this tension prevented further flexion of the straightened 
limb. 

The results of treatment were almost always very good, the limb 
showing a complete restoration of form and function after a few weeks ; 
but in two cases the result was not entirely satisfactory. Six weeks 
after birth the leg in Perier's case showed exaggerated extension and 
outward rotation; the quadriceps was manifestly retracted, and showed 
as a tense cord whenever the attempt was made even slightly to flex the 
leg. In the hope of an ultimate return to the normal condition, Gueniot, 
who then had charge of the case, limited treatment to the maintenance 
of the extended position and to slight passive flexion and traction repeated 
two or three times daily. In the other case, Maas, the limb when first 
seen was in dorsal flexion at a right angle ; reduction was easily made, 
and the limb could then be normally flexed. It was placed in a plaster- 
of-Paris dressing for six weeks, and as the tendency to recurrence had 
not then entirely disappeared the dressing was renewed for a time, and 
afterward a leather knee-cap was worn. In its second year the child 
walked for a time without support, but at the time of the report, when it 
was two and a half years old, there was still a tendency to anterior flexion 
and abduction, and a brace was constantly worn. 

Of the subsequent history of the only case of backward dislocation, 
Hamilton, in which the dislocation was reduced after division of the 
hamstring tendons, there is no mention. 

Spontaneous or Pathological Dislocations. 

These are very frequent at the knee, mainly as the result of chronic 
disease involving the ligaments and the bones of the joint, and of pro- 
longed maintenance of the partly flexed position. There are also instances 
on record of sudden dislocation due to muscular contraction during an 
acute arthritis, and quite a number of the class to which Volkmann gave 
the name deformations-luxationen, or dislocations by deformity, those in 
which the shape of the articular ends of the bones has been greatly 



CONGENITAL DISLOCATIONS. 489 

changed without suppuration, as in arthritis deformans and Charcot's 
disease. 

The principal displacements are backward and backward and outward, 
usually combined with outward rotation of the leg. As a great exception 
dislocation forward has occasionally been observed. 

An example of a sudden dislocation backward and upward occurring 
in the course of a rheumatic attack has been quoted in Chapter X., page 
113, from Verneuil. 

Examples of dislocation due to the prolonged action of the flexor 
muscles, the knee being long held partly flexed because of disease at 
some point in the thigh, are not very uncommon, and in young people 
its effect is intensified by the exaggerated growth of the femoral condyles 
downward by which the lateral ligaments become too short to permit the 
tibia to return to its place. This last mentioned change was first pointed 
out by Volkmann in 1874, and deserves to be constantly borne in mind, 
for if the attempt is made forcibly to straighten such a limb the tibia may 
turn upon its anterior edge as a centre, so that when straightened it is 
found to lie well behind its proper position, " dislocation by leverage," as 
it has been termed. One such instance I saw in a lad of twelve years 
who had long suffered from caries of the lower portion of the shaft of the 
femur, the knee-joint not being involved in the disease. 

The dislocations that occur in the course of chronic tubercular or other 
destructive disease must here be passed with simple mention. 






CHAPTEE XXIX 



DISLOCATIONS OF THE PATELLA. 



Dislocations of the patella are rare, about one per cent, of all dislo- 
cations, according to the tables in Chapter I., and the infrequency with 
which they have come under the observation of individual surgeons and 
the incompleteness or the obscurity of the reports of many cases have 
combined to make the systematic descriptions rather artificial and unsat- 
isfactory. The physical conditions and relations of the patella, which is 
really a sesamoid bone developed in the tendon of the quadriceps extensor 
and not an integral part of a joint, are entirely different from those of 
other bones, and the changes in position and relations which it undergoes 
in displacement are very varied. The anterior articular surface, or troch- 
lea, of the femur extends higher upon the outer than the inner side and 
presents a central groove bounded laterally by a sharp margin from which 
the internal and external surfaces of the inner and outer condyles, respect- 
ively, run abruptly backward, and the outer condyle projects more sharply 
forward than the inner one does. The articular or posterior surface of 
the patella presents a longitudinal ridge nearer its inner than its outer 
margin from which the surface slopes forward to the edge. From each 
lateral border of the bone passes a strong aponeurotic expansion, the 
so-called lateral ligaments of the patella, portions of the fascia lata which 
receive expansions from the vasti muscles and are attached to the tibia ; 
of the outer one, the " ilio-tibial ligament" is the strongest part and tends 
to displace the patella outward when the knee is flexed. A superficial 
layer, given off from the fascia lata on the sides, crosses the front of the 
patella and is separated from it by a bursa. In full extension of the knee 
the patella lies upon the upper part of the trochlea of the femur, but it 
can be drawn almost completely above it by the forcible contraction of 
the quadriceps. This muscle is inserted upon the upper border and 
somewhat on each side of the patella, and the long axis of the muscle is 
inclined to that of the patella and its ligament as the shaft of the femur 
is to that of the tibia — that is, they meet at an obtuse angle whose apex 
is directed inward. As a consequence of this inclination the traction of 
the muscle tends to displace the bone toward the outer side, and this 
tendency is resisted by the projection of the anterior surface of the outer 
condyle and by the internal lateral ligament of the patella. 

The first collation of recorded cases was made by Malgaigne 1 in 1836; 
the 25 cases which he then collected were increased to 46 in 1855, when 
he published his work on dislocations. Streubel 2 in 1866 collected 120 
cases and made a number of experiments upon the cadaver. Elaborate 

1 Malgaigne : Gazette Medicale, 1836, p. 433. 

2 Streubel : Schmidt's Jahrbuch, 1866, vol. 129, p. 311, and vol. 130, p. 54. 



DISLOCATIONS OF THE PATELLA. 491 

articles were furnished by Panas 1 in 1872, and Berger 2 in 1877, but the 
most original and at the same time the most recent one is the paper by 
Yon Meyer, 3 Professor of Anatomy at Zurich. 

The patella may be displaced to different distances on the outer or the 
inner side while the knee is extended or partly flexed, and with such 
displacement may be combined varying degrees of rotation about its own 
longitudinal axis. These combinations are so numerous and varied that 
if a classification should be made according to them it would confuse 
rather than simplify their study and description. Malgaigne in his first 
paper, based on only 25 cases, described nine forms of dislocation, includ- 
ing an upward and after rupture of the ligamentum patellae, but in his 
later work he made only two principal forms, dislocation outward and 
inward, with subvarieties corresponding to the degree of displacement and 
the addition to it of more or less rotation of the patella upon its axis. As 
some of the most striking differences depend upon this last element it will 
perhaps simplify the subject first to consider the conditions which deter- 
mine the fixation of the displaced bone, and in doing this I shall speak 
only of displacements to the outer side, which are much the more common. 

The bone may be displaced to the outer side by muscular action or by 
n force acting upon its inner lateral border ; as it passes sideways along 
the projecting surface of the condyle its outer border is raised and its 
inner border depressed into the bottom of the trochlear groove ; if the 
force continues to act the patella is carried past the edge of the trochlea 
to the outer side of the external condyle, and when its longitudinal ridge 
passes this edge the outer border of the patella may be turned backward 
by the traction of its outer lateral attachments and the bone comes to rest 
with its articular surface against the outer side of the condyle, and its 
anterior surface looking outward ; or it may undergo no rotation, and 
may come to rest with its inner border against the outer surface of the 
condyle, its anterior surface looking more or less directly forward, and 
its outer border projecting markedly outward; or, again, it may undergo 
rotation in the opposite direction and come to rest with its inner border 
directed backward, its anterior surface looking inward against the outer 
surface of the condyle, and its outer border directed forward. These 
three forms constitute the "complete outward dislocations." 

If the force is not sufficient to carry the patella entirely past the outer 
edge of the trochlea, the bone may come to rest with its inner border in 
the bottom of the trochlear groove, its posterior surface resting partly 
against the outer surface of the trochlea and partly projecting beyond it, its 
outer border directed forward and outward, and its anterior surface look- 
ing forward and inward — the " incomplete outward; " or the rotation may 
be somewhat greater, and while the inner border still rests in the groove 
of the trochlea the outer border looks directly forward, and the anterior 
surface directly inward — "vertical" or "edgewise" dislocation; or the 
rotation may be still greater, the anterior surface being turned so as to look 
directly backward and lie upon the front of the trochlea, and the posterior 
surface looking directly forward under the skin — "complete reversal." 

1 Panas : Diet, de Med. et Chir. pratiques, vol. 16, p. 40, art. Genou. 

2 Berger: Diet. Encyclop, des Sc. Med., 3d series, vol. 5, p. 334, art. Kotule. 

3 Von Meyer : Arch' fur klin. Chirurgie, 1882-3, vol. 28, p. 256. 




492 DISLOCATIONS OF THE PATELLA. 

It appears, then, that the bone frequently becomes fixed, and firmly 
fixed, in positions of apparently great instability — that is, resting upon 
the front or side of the femur only by its narrow lateral edge, and the 
fixation which is given to it in these positions is given by the tension of 

the soft parts attached to it and by the 
Fig. 157 - overlying fascia. It may be compared to 

a stick on end under a tightly stretched 
;-.., ;\ 7 sheet, which will stand not only upright, 

but also when inclined, so long as its lower 
end does not slip along the ground, or its 
upper along the sheet. 

It also appears, in consequence, that the 
bone may take many intermediate positions 
between the extremes, and that conse- 
quently the grouping of the different 
positions must be somewhat arbitrary. The 
terms in general use are complete and in- 
complete outward and inward dislocations, 

Diagram of the various dislocations of 7 ± 7 • -, -,. 1X 

the pateiia. edgewise or vertical (outward and inward) 

dislocations, and complete reversal in either 
of the two directions. Dislocations upward and downward should not, I 
think, have a place in the classification, since they are the secondary 
results of other lesions, rupture of the ligamentum patellae, or of the 
tendon of the quadriceps, which are to be deemed the principal and con- 
trolling ones. Among the incomplete outward and inward dislocations 
those in which one edge of the patella is turned sharply forward differ 
from the corresponding edgewise ones only in the degree of rotation, and 
the distinction between them is not only difficult to make in practice, but 
also does not seem worth preserving. I shall, therefore, group them all 
as edgewise dislocations, and limit the term incomplete to others in which 
the rotation is absent or slight. 

The outward dislocations are much the more common ; it is doubtful 
if any really complete inward dislocation has been recorded, and of Mal- 
gaigne's 46 cases only 6 were incomplete inward. Of the vertical or 
edgewise dislocations the outward appear to be somewhat more frequent 
than the inward. 

Cause. — The cause and mode of production of the different forms are r 
in many respects, the same. The dislocation may be produced either by 
muscular action, contraction of the quadriceps, or by external violence 
acting directly upon the patella. Of the former there are many unques- 
tionable examples ; a man dislocates the patella while fencing, a woman 
by jumping backward and to one side, a boy by jumping upward and 
turning partly around to strike a ball. Of the latter, external violence 
acting directly upon the patella, the common examples are falls and blows 
upon the knee ; in several instances a man riding a horse has struck his 
knee violently against another moving in the opposite direction. In a 
number of cases it has been noted that the knee was previously affected 
with hydrarthrosis, and in a few genu valgum existed. In the cases of 
frequent, or habitual, dislocation some such predisposing cause is supposed 
always to exist. 



OUTWARD DISLOCATIONS. 



493 



Outward Dislocations. 
1. Complete. 

In complete outward dislocations the patella is displaced entirely to the 
outer side of the external condyle, against which it rests either by its 
posterior, cartilaginous surface, or, more rarely, by its inner border, its 
anterior surface being still directed forward, or by the inner part of its 
anterior surface, the outer border projecting forward and the anterior 
surface looking inward. 

According to von Meyer, and his opinion is based upon clinical obser- 
vations, as well as upon anatomical and experimental data, the patella 
can reach this position either by passing outward at or above the upper 
part of the trochlea in complete extension or hyperextension of the knee, 
or by passing outward and upward over the lower border of the condyle 
while the knee is flexed nearly to a right angle. In the former case the 
dislocation may be produced by muscular action, the contraction of the 
quadriceps extensor, by which the patella is raised so high that its pas- 
sage is no longer resisted by the outer border of the trochlea, and the 
displacement is further favored by the outward rotation of the leg which 
takes place at the end of extension, and which makes more acute the 
obtuse angle formed by the junction of the quadriceps and the ligamentum 
patellse. Hyperextension of the knee favors the displacement by carrying 
the patella still higher above the trochlea. Other conditions that favor 
the displacement are exaggerated outward rotation of the leg and bending 
inward of the knee. As illustrative examples 
Meyer quotes cases reported by Foucart and 
Robert. A muscular young man jumping 
down from a stool (apparently backward) felt 
a sharp pain, and found he could no longer 
stand on the right foot ; examination showed 
an outward dislocation of the patella. A 
woman, carrying a heavy burden upstairs, 
felt sharp pain and a cracking in the right 
knee, and was unable to walk ; the patella 
was dislocated outward. 

External violence can produce the disloca- 
tion at the same, upper, point. 

In either case the further displacement of 
the patella downward upon the outer surface 
of the condyle and its fixation there are aided 
by the subsequent flexion of the knee which 
involuntarily follows upon the sensation of an 
injury received there. 

In studying the manner in which displace- 
ment took place, by external violence, while 
the knee was partly flexed, von Meyer found 
that the resistance of the ligamentum patellae compelled the bone to move 
in a curve downward and outward, so that it lodged over the lower part 
of the condyle, or even in the groove between it and the tibia, and the 



Fig. 158. 




Complete dislocation of the patella 
outward. (Anger.) 



494 DISLOCATIONS OF THE PATELLA. 

tendon of the quadriceps slipped sidewise over the edge of the trochlea,, 
and lay upon the outer surface of the condyle. 

The pathology of the commoner form has been studied only in experi- 
ments upon the cadaver and in specimens of old unreduced dislocations, 
of which seven cases have been reported. In four of these seven cases 
the internal lateral ligament of the patella was torn, and in one the rent 
extended upward in the vastus internus more than three inches above 
the patella. Experiments upon the cadaver confirm these facts. Fig. 
158 represents a specimen obtained experimentally. It may be added 
that in three cases of long standing the bones had undergone various 
changes ; in some the patella was hypertrophied, in others atrophied ; in 
some it had lost part or all of its articular cartilage ; in some the leg was 
distinctly rotated outward, presumably the result of the traction exerted 
upon it through the ligamentum patellae. 

The only examination of an uncomplicated recent case of which I have 

knowledge is one reported by Andrews ; l the specimen was obtained by 

amputation, which was rendered necessary by a compound fracture of the 

leg. The displacement was of the rare form in which the patella has 

undergone no deviation about its longitudinal axis and 

Fro. 159. rests against the external condyle only by its inner 

border (Fig. 159). The patient had been run over by a 

freight car. " The patella was found shoved nearly 

straight outward with its inner edge resting firmly against 

the outer condyle, and with its front and back surfaces 

presenting in a nearly normal direction At 

the place where the inner border of the patella rested 
against the femur the shell and spongy tissue of the con- 
dyle were crushed in, making an oval or spoon-shaped 
hollow about one inch long and five-eighths inch wide. 
The sharp inner edge of the patella rested firmly in this 
hollow and was thus effectually prevented from slipping. 
The rest of the patella was stoutly held in position, like 
tl ^ a tent-pole or derrick, by tight bands drawing in three 
patella outward. different directions, as follows: 1. By a portion of the 

vastus externus muscle drawing the outer angle upward, 
inward, and backward. 2. By a part of the rectus femoris, not repre- 
sented in the figure, but drawing in the direction of the dotted line R, 
upward, inward, and forward. 3. By the ligamentum patellae, drawing 
downward and inward. 

" The vastus internus was torn off. The inner half of the rectus was 
torn off with the vastus internus, and the lateral attachments of the 
capsular ligament to the sides of the patella were effectually ripped away, 
but the outer part of the rectus, was still attached." 

The symptoms are loss of power to stand upon the limb or actively to 
move the knee, pain, and deformity. The knee is usually partly flexed, 
but occasionally has been found fully extended. Passive motion is 
painful, complete extension usually possible, further flexion rarely 
possible. 

1 Andrews: Annals of Anat. and Surgery, 1883, vol. 7, p. 199. 




Andrews's case of 
dislocation of 



OUTWARD DISLOCATIONS 



495 



Fig. 160. 



The knee appears broadened and flattened anteriorly ; the normal 
prominence of the patella is lost, and in its place is a depression through 
which the anterior articular surface of the condyles can be distil ctly 
traced unless the swelling is too great. The patella can be readily felt 
upon the outer side of the condyle, and the 
tendon of the quadriceps and the ligamentum 
patellae show as tense bands under the skin. 
Usually the patella rests with its articular 
surface against the outer surface of the con- 
dyle and its inner border directed forward, 
but, as has been already said, it may stand 
directly out from the condyle, resting against 
it by its inner border only, or it may be 
rotated in the opposite direction so that its 
outer border is directly in front. Of this last 
form a case was reported by Parkes, 1 which 
may be quoted in illustration. The patient 
made a misstep and fell to the ground, striking 
his bent knee against a large piece of coal ; 
the leg was slightly flexed and immovable. 
" The inner edge of the patella Avas thrown 
entirely external (to the condyle), clearing the 
femoral articular surface absolutely, and 
rested against the outer tuberosity of the ex- 
ternal condyle of the femur, so that the inner 
border of the displaced bone was fully half an 
inch behind the highest point of the outer 
rim of the trochlear facet of the femur." " Its 

subcutaneous surface was turned inward, and its articular surface 
ward." "The ligamentum patellae was very tense, and so also in a 
remarkable degree was the ilio-tibial band of the fascia lata." Flexion 
of the knee turned the outer border backward, and Parkes took advantage 
of this fact to reduce ; he flexed the knee as far as possible, and then 
with the end of his pocket-knife pushed the inner edge of the patella 
forward over the edge of the trochlea ; then the knee was extended, and 
the bone returned to its place. Similar cases have been reported by 
Mayo, 2 Grasnick, 3 and Faucon. 4 

Treatment. — The method of treatment that has proved the most suc- 
cessful is one proposed more than a hundred years ago by Valentin, 
which consists in full extension of the knee and flexion of the hip to 
relax the quadriceps, followed by direct pressure with the hands upon the 
patella ; it may be necessary to increase the laxity of the tendon of the 
quadriceps by pressing the lower part of the muscle downward toward 
the knee. Possibly a device which Duplay employed successfully in a 




Dislocation of the patella outward. 
(Duplay.) 



OUt- 



1 Parkes: Chicago Med. Journ. and Ex., 1883, vol. 46, p. 887. 

2 Mayo : Lond. Med. Gaz., 1828; quoted by Malgaigne, loc. cit., p. 911. Maigaigne 



doubts the correctness of the diagnosis. 

3 Grasnick : Preuss. mil. arztl. Zeitung, 1862, 
p. 347. 

4 Faucon : Bull, de la Soc. de Chirurgie, 1887, p. 



1 ; quoted by Berger, loc. cit. 



496 DISLOCATIONS OF THE PATELLA. 

vertical dislocation might be used, if pressure with the hands failed ; he 
inserted the points of a strong double hook through the skin, engaged 
them under the edge or in the anterior surface of the patella, and drew 
the bone forward. Moreau did an arthrotomy, but the joint suppurated 
and the patient barely escaped with his life. Albert and Konig speak 
rather lightly of the risk involved in such an operation, and the latter 
employed it in a case of three months' standing, but whatever confidence 
surgeons may have in antiseptic methods they will, I think, be slow to 
resort to this measure. 

In cases that have remained unreduced the usefulness of the limb has 
sometimes been well restored, the patients being able to walk freely and 
troubled only in making complete extension. In other cases, again, the 
disability has been great, the knee being stiff and the patient able to walk 
only with crutches. Occasionally the accident is followed by a marked 
tendency to recurrence on flexion of the knee. 

2. Incomplete. 

The cases to which I limit this group are those in which the dislocation 
takes place while the knee is extended, and in which the patella rests 
above and partly to the outside of the outer part of the femoral trochlea, 
its apex being probably still on the median side of the crest. It is to be 
remembered that in most systematic descriptions the group is made also 
to include cases of moderate edgewise or vertical displacement, those in 
which the inner border of the patella rests in the hollow of the trochlea 
and the outer border projects outward and forward; but still the majority 
of the reported cases are of the kind to which I have restricted the use of 
the term. There are, however, cases of habitual dislocation in which the 
patella moves outward during flexion of the knee and the outer border 
turns backward, which might properly be termed incomplete. Malgaigne 
(loc. cit., p. 912) reports one such in which the condition followed a 
primary traumatic dislocation, and a number have been reported in which 
the condition developed gradually or was thought to have existed at birth. 

The causes are essentially the same as those which produce the complete 
outward dislocations in which the patella escapes at or above the upper 
part of the trochlea, that is, muscular action and external violence received 
while the knee is fully extended or even hyperextended. 

Yon Meyer finds the explanation of the incompleteness of the disloca- 
tion in the supposition that the lateral movement of the patella takes 
place while it is still at a lower point upon the femur than it is when it 
undergoes displacement outward ; the outer margin of the trochlea 
engages in the sulcus at the junction of the patella and ligamentum 
patellae, and thus the bone is prevented from being drawn further outward 
by the traction of the ilio-tibial band. 

Direct examination has been reported in only one case, and that an 
old one, Diday ;* the specimen came from a man thirty-four years old ; 
the deformed patella rested on the external condyle and was prevented 
from moving inward by a bony ridge which occupied the trochlea ; the 

1 Diday : Bull, de la Societe Anatomique, 1836, p. 297. 



VERTICAL DISLOCATIONS. 497 

articular surface extended an inch higher upon the outer than upon the 
inner condyle. The patient walked without difficulty. 

The limb is in extension, and any attempt to flex is painful. The 
inner half of the trochlea can be distinctly traced with the finger, and 
the patella can be recognized above and to the outer side of its normal 
position, with its anterior surface looking almost directly forward, and if 
inclined at all it appears to be usually inclined outward. 

The treatment is the same as that of the complete form : flexion of the 
hip and extension of the knee to relax the quadriceps, followed by direct 
pressure inward upon the patella. Reduction is easy and sometimes 
spontaneous ; in a case reported by Cooper the reduction followed 
immediately and spontaneously upon the displacement, the only proof of 
the dislocation being a demonstrable rupture of the inner anterior part 
of the capsule and swelling of the joint. 

3. Outivard edgewise or vertical dislocations. 

According to Malgaigne this form of dislocation was first reported in 
1777 by Nannoni, an Italian surgeon, who communicated two cases to 
the Academie royale de Chirurgie. His account appears not to have 
been credited, and the subject was not again mentioned until Malgaigne, 
in 1836, gave a description of it. Since that time a considerable number 
of cases have been reported ; without making a very thorough search I 
have found about thirty, five of which were reported in the New York 
Medical Record between the years 1873 and 1879, and in this enumer- 
ation I have not included cases reported as incomplete outward dislocations, 
although I include such in the classification. 

The dislocation is characterized by a displacement outward of the 
patella and its rotation upon its longitudinal axis, by which its inner 
border is brought to rest at or near the bottom of the groove of the troch- 
lea, while the outer border projects more or less directly forward and its 
anterior surface looks inward ; it is said by Panas that its apex is also 
directed slightly backward. 

Muscular action is the most frequent cause, and in some cases the 
contraction of the muscle appears not to have been forcible, as in 
Martin's 1 patient, a young girl, who caused the dislocation by moving in 
bed ; in others more force has been exerted, as a boy in throwing a snow- 
ball, a man in wrestling, another in stumbling, another in jumping. 
External violence is a less frequent cause ; a blow upon the inner edge 
of the patella by which the bone is pushed outward, its inner border 
depressed into the hollow of the trochlea, and its outer border raised by 
the passage of the bone along the slope of the external condyle. The 
mode of production by muscular action has not been made clear. 

The patella may rest partly against the projecting outer portion of the 
trochlea, or it may touch the femur only by its inner edge even when its 
outer border still lies somewhat to the outer side of a sagittal plane 
passing through the inner one, and in one case, Payen, quoted by Mal- 
gaigne, the patella had turned more than 90°, so that its outer border lay 

1 Martin : Arch. gen. de Med., 1831, vol. 26, p. 259. 
32 



498 DISLOCATIONS OF THE PATELLA. 

a little to the inner side of the inner border. Its fixation in this position 
without lateral support must be attributed to the tension of the overlying 
soft parts and the untorn parts of the capsule, for in one case in which 
both the tendon of the quadriceps and the ligamentum patellae were cut 
subcutaneously by the surgeon in the effort to reduce the bone remained 
as firmly fixed as before. 

The knee is generally extended, but in some cases it was flexed half 
way to a right angle, and is usually immovable because of pain. The 
deformity is characterized by the sharp projection of the outer border of 
the patella in front, on each side of which the skin is depressed so that 
the anterior and articular surfaces of the patella can be felt, but some- 
times the skin is stretched tightly toward each side. 

The most successful treatment has been that recommended for the 
preceding forms : flexion of the hip, extension of the knee, and pressure 
upon the patella, the latter being so directed as to force the projecting 
outer border outward and backward, but this has failed in several cases 
in which reduction was afterward obtained by forced flexion of the leg or, 
in one case, by getting the patient forcibly to contract the quadriceps 
and then pressing upon the patella after it had been thus drawn upward. 
Possibly Duplay's device, above mentioned, of drawing the patella forward 
with a strong sharp hook, would be of use by diminishing the friction 
between it and the femur. Eben Watson, and others following his 
example, succeeded by slightly flexing the leg upon the thigh during 
anaesthesia, pressing the patella moderately outward, and then suddenly 
extending the leg. Three surgeons have resorted to section of the liga- 
mentum patellae, and one of them also to that of the tendon of the 
quadriceps, but without success, and in the last one the joint suppurated 
and the patient died. 

4. Complete reversal. 

Complete reversal, the outer border passing in front to the inner 
side, so that the anterior surface rests against the trochlea and the artic- 
ular surface is directed forward, has been reported in only two cases 
which are briefly quoted by Malgaigne as follows ; " In 1752 J. Sue saw 
a dislocation produced by muscular action in which he clearly recognized 
a two-thirds reversal of the patella from without inward without any 
evidence of rupture of the ligaments. Subsequently Hevin said that he 
had heard Bruyeres read before the Academie royale de Chirurgie the 
details of a total reversal of the patella upside down, also without rup- 
ture of the ligaments ; in the latter case the cause was a blow received 
upon the inner part of the knee." 

Inward Dislocations. 

These are so similar to the outward dislocations in their nature, causes, 
symptoms, and treatment that a detailed description is unnecessary. 

Complete Inward. — This dislocation is denied by several authors, 
the only alleged cases being those of Putegnat and Walther, both quoted 
by Malgaigne. The former was traumatic in origin, but when the patient 



INWARD DISLOCATIONS. 499 

came under observation the condition was that of habitual dislocation : 
the patient, a girl thirteen and a half years old, had fallen upon her 
knees five years before, and since that time both patellae had been so 
freely movable that she sometimes amused herself by dislocating and 
reducing them more than a hundred times in an hour. The right 
patella could be more easily dislocated outward, the left one inward ; but 
both could be dislocated so completely inward that their anterior aurfaces 
were exactly in contact when the knees were brought together. The 
ligaments were so relaxed that the legs could not be completely extended 
by the contraction of the quadriceps. 

Of Walther's case, nothing is known but a brief description in Latin 
of a specimen in a museum at Berlin. Malgaigne thought it might be 
a complete inward dislocation, but admits that its character is uncertain. 

Of incomplete inward dislocation only one case has been reported, by 
Key ; l it also was quoted by Malgaigne. The patient, a girl twenty 
years old, slipped and fell ; she felt great pain in the left knee, and was 
unable to walk. "The patella was found resting on the inner condyle, 
the outer part of its articulating surface being supported obliquely by the 
projecting edge of the trochlea of the femur. Gentle pressure on the 
inner edge of the patella, as the limb lay on the bed, reduced it to its 
natural position." The joint suppurated, and apparently the patient died 
or the limb was amputated. The tendon of the vastus externus was 
partly torn through. 

Inivard edgewise or vertical dislocation. — This seems to be nearly as 
frequent as the corresponding outward form. Possibly its relative frequency 
and the rarity or absence of the complete and incomplete inward forms 
are to be explained by the greater projection inward of the internal con- 
dyle, and the relative shortness of the ligamentum patellae, which prevents 
the patella from reaching that side of the condyle. 

Complete reversal, the inner border passing in front to the outer side, 
has been reported in three cases, Castara, quoted by Malgaigne, Wragg, 2 
and Gaulke. 3 

Castara's patient, a girl seventeen years old, bent forward to lift a book 
from a table, resting her weight upon the extended right leg, and pressing 
the outer border of the patella against the edge of a chair ; she suddenly 
cried out, and Castara, summoned immediately, found the leg partly flexed, 
and could extend it but very little. The patella rested by its outer border 
upon the outer and upper part of the trochlea of the femur, which it 
covered only over a breadth of a quarter of an inch ; its inner border 
inclined outward and projected in this direction two and a half centi- 
metres, its articular surface looking forward and inward. The tendon of 
the quadriceps and the ligamentum patellae each formed a quite thick and 
hard rounded cord above and below. The surgeon grasped the bone with 
his thumbs and forefingers, and by a simple movement of rotation from 
behind forward, and from without inward, restored it easily to its place. 

Wragg's patient was a negro, who had been struck upon the outer side 

1 Key : Guy's Hosp. Beports, 1836, vol. i. p. 260. 

2 Wragg : Charleston Med. Journ., May, 1856, abstract in Schmidt's Jahrbuch, 
1856, vol. T 91, p. 362. 

3 Gaulke : Deutsche klinik, 1863, p. 108. 



500 DISLOCATIONS OF THE PATELLA. 

of the right patella. The limb was extended and immovable. The inner 
border of the patella had turned forward and outward, and lay about half 
an inch to the outside of the normal position of the outer border ; the 
outer border could be felt deep in the trochlea about half an inch from its 
inner edge. The tendon of the quadriceps and the ligamentum patellae 
showed under the skin as hard twisted cords ; very little passive motion 
at the knee. The dislocation was reduced quite easily by pressing with 
the thumbs against the projecting inner border, and with the index and 
middle fingers against the outer border in the opposite direction. The 
reaction was slight, and the patient made a good recovery. 

Gaulke's patient, a girl seventeen years old, injured her knee in a fall 
from a horse, and was not seen by him until ten days after the accident. 
"The patella lay entirely upon the outer condyle of the femur, and had 
been so turned about its longitudinal axis that its posterior surface looked 
forward and inward, and the anterior surface backward and outward." 
After several failures he reduced by making pressure against the project- 
ing inner border with one jaw of a vise, such as is used by carpenters to 
hold pieces of wood that have been freshly glued together, the counter- 
pressure being made with the other jaw against the internal condyle. 
The force of the screw was so applied as to press the inner border of the 
patella forward and inward, while its outer border was expected to move 
along the outer slope of the trochlea. After many efforts, the patella 
suddenly moved with a snap, turned about its long axis, and fell back 
into place. The patient recovered in a fortnight. 

Congenital Dislocations. 

In a number of reported cases the term congenital has been used 
although the writers knew that the dislocation had first appeared long 
after b rth ; in most of the others it has not been possible to ascertain 
with certainty the date of the appearance of the condition, and in many 
the probability is very great that it had been gradually developed long 
after birth. The reported cases in which it is reasonably certain that the 
condition existed at birth are not numerous, perhaps fifteen or twenty, but 
if to these are added the other cases which several of the patients have 
said existed in other members of their families, the number becomes con- 
siderably increased. The principal paper upon the subject is one by 
Zielewicz ; l Bessel-Hagen 2 recently read one before the Berlin Medical 
Society, and presented two cases, but the published abstract is very 
short. Zielewiczs paper gives the details of 13 cases, in 3 of which the 
patella was dislocated upward with elongation of its ligament; in the 
remaining 10 the dislocation was outward. The congenital character of 
the first 3 is uncertain. Of the outward ones in which the sex is noted, 
6 were males, 3 females ; in 5 both patellae were dislocated, and in all the 
patients were able to make good use of the limb. 

Bessel-Hagen points out that the cases may be grouped in three classes : 
1. The incomplete, in which the patella lies upon the outer condyle when 
the knee is extended, and returns to its normal place when the knee is 

1 Zielewicz: Berlin, klin. Wochenschrift, 1869, vol. 6, p. 25. 

2 Bessel-Hagen : Deutsche med. Wochenschrift, 1881, p. 45. 



SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS. 501 

flexed ; 2, complete intermittent, in which the displacement occurs during 
flexion ; 3, complete permanent, in which the displacement is increased 
during flexion, and is not overcome during extension. 

A case reported by Lannelongue 1 is less open to criticism than most, 
for the displacement was recognized at birth. The patient was a girl, 
seven years old at the time of the report. The right patella lay on the 
side of the outer condyle and was very movable, but could not be brought 
back to its normal place ; the groove of the trochlea was almost effaced. 
There was no lateral mobility of the knee ; the normal movements were 
free. When the child was told to raise the limb she first flexed the knee 
a little and then extended it rapidly. The right limb was smaller than 
the other, both in length and fulness, the femur being two centimetres, 
the tibia one centimetre, shorter than its fellow. 

Caswell 2 reported a case of congenital dislocation of both patelhe in a 
man, forty-three years old, who said that five members of his family, in 
three generations, had the same deformity — his father, sister, son, and 
nephew\ Dr. Caswell examined the son and confirmed the statement to 
that extent. 

Shapleigh 3 saw a man, thirty-nine years old, both of whose patellae 
" were dislocated outward, resting on the upper and outer surface of the 
external condyle of the femur." They were of normal size. The patient 
said the condition had existed from birth, and that his grandfather, father, 
and one of his own children, four generations, had the same deformity. 
The man walked without difficulty and had served as a soldier during the 
war. 

An anonymous writer 4 reported a case of congenital dislocation of both 
patellae in a girl whose father, aunt, and aunt's daughter were in the same 
condition. 

Bessel-Hagen's two patients were brothers ; in one the dislocation was 
intermittent ; in the other permanent, with much disability, strong rota- 
tion inward of the femur, and slight contracture in the direction of flexion 
at the hip and knee. 

Spontaneous or Pathological Dislocations. 

A number of varying conditions in the bones or ligaments of the knee 
may have for consequence the frequent, even habitual, dislocation of the 
patella in certain positions or movements. Almost without exception, 
these dislocations are to the outer side and complete. Many cases reported 
as congenital are probably of this character ; Isemeyer, 5 indeed, published 
an elaborate paper on the subject in which he claimed that all reported 
cases of congenital dislocation were really pathological ones. 

Among the alleged causes are chronic hydrarthrosis, relaxation of the 
ligaments, chronic arthritis of different kinds, and malformation of the 
knee, especially genu valgum. 

1 Lannelongue: Bull, de la Soc. de Chirurscie, 1880, p. 238. 

2 Caswell : Am. Journ. Med. Sc, July, 1865. 

3 Shapleisrh : Boston Med and Surg. Journ., 1881, vol. 105, p. 252. 
* N. Y. Med. Journal, 1885, vol. 42, p. 27. 

5 Isemeyer: Arch, fur klin. Chirurgie, 1866, vol. 8, p. 1. 



502 DISLOCATIONS OF THE PATELLA. 

Chronic hydrarthrosis has been claimed by several writers to be a 
frequent cause, and many illustrative cases have been published ; but I 
think it must be conceded that something more than the simple presence 
of an effusion in the joint is needed to produce the condition, for all are 
familiar with cases in which an effusion, and even a very large one, has 
existed for years without creating any recognizable tendency to dislocation 
of the patella. This additional cause may be a softening and relaxation 
of the ligaments, itself due also to the cause of which the effusion is an 
effect. 

In genu valgum the increased abduction of the leg upon the thigh 
produces a corresponding exaggeration of the angle between the quadri- 
ceps and the ligamentum patellae in consequence of which the contraction 
of the muscle constantly tends to draw the patella outward, and if the 
patella passes to the outer side of the outer condyle the muscle then aids 
still further to abduct the leg and increase its deviation. Indeed, in some 
of the reported cases it has remained in doubt whether the abduction of 
the leg preceded or was itself the consequence of the dislocation of the 
patella. 

The patella is habitually very movable, and the dislocation takes place 
or is increased during flexion of the knee and is reduced or diminished 
during extension. The functions of the limb are more or less interfered 
with, complete voluntary extension being difficult or impossible. The 
femur tends to rotate inward, and the leg outward and to become 
abducted. 

A case which resembles Putegnat's of complete inward dislocation in 
the facility with which the patient could rapidly reduce the dislocation 
by muscular action is reported by Albert ; x the patient was a boy, sixteen 
years old, with genu valgum on the affected side. When the knee was 
held at an angle of 160° he could repeat the production and reduction 
with great rapidity and ease. Flexion at 150° was the limit at which 
voluntary reduction could be made ; voluntary dislocation was possible 
even when flexion was carried to 90°. 

The treatment consists in the wearing of a knee-cap designed to oppose 
the displacement during flexion or to restrict the flexion to the range 
beyond which the displacement took place. 

In a case reported by Golding Bird 2 it was believed that "the cause 
of the displacement was due to structural shortening of the quadriceps 
extensor following paralysis of the muscle — probably infantile," and 
tenotomy of the ligamentum pateltae was done, but without benefit. 

1 Albert: Chirurgie, vol. 4, p. 396. 

2 Bird : Lancet, 1884, ii. p. 778. 



CHAPTEE XXX 



DISLOCATIONS OF THE FIBULA. 



The fibula may be dislocated at its upper or at its lower end, and as 
the result of external violence, or of muscular action, or of unequal 
growth of the tibia and fibula. 

A. Dislocations of the ujiper end. 

These are among the rarest dislocations ; Malgaigne, excluding cases 
complicated by fracture of the tibia or of the fibula, collected only 5 
reported instances, and I have been able to increase the list only to 18, 
of which 6 were forward, 5 backward, 3 upward, 1 outward, and in 3, 
Driefly mentioned by Bryant, the direction is not stated. It is to be 
remembered that as the head of the fibula is situated behind the most 
external part of the tibia a dislocation forward must also be outward. 
The cases are those of Dubreuil, Jobard, Savournin, Thomson and Boyer, 
quoted by Malgaigne, Stoll, 1 Richardson, 2 Sorbets, 3 Melzer, 4 Robert, 5 
Oldright, 6 Read, 7 Parkinson, 8 Bryant, 9 and Erichsen. 10 

Of cases complicated by fracture of either the tibia or fibula, or of both 
Dones, quite a number have been reported ; several associated with frac- 
ture of the upper end of the fibula have been quoted in Fractures, page 
586, and one of an exceptional form on page 580. Of those in which the 
dislocation is a complication of fracture of the tibia, and is produced by 
the overriding of the fragments bv which the head of the fibula is forced 
upward, it is only necessary to say that, although the reported displace- 
ment has been very great in some cases, it does not appear seriously to 
have affected the treatment of the fracture, and in most cases reduction 
was easy. In some, in which the fracture united with shortening, there 
remained a permanent displacement of the head of the fibula upward. In 
a specimen presented by Shaw, 11 in which the tibia had been broken in 
its lower third and had united with much shortening, and in which the 
fibula also had been broken in two places, " the articulating surface of 
the head of the fibula was elevated to the same level as that of the tibia 

1 Stoll: Med. Corresp. Blatt., 1881, p. 300. 

2 Richardson: Am. Journ. Med. Sei., 1863, vol. 45, p. 385. 

3 Sorbets: Med. Corresp. Blatt., 1868, p. 279. 

* Melzer: Allgem. mil. arzt. Zeitung, 1871, vol. 12, p. 140. 

5 Robert: Rec. de mem. de med. chir. et pharm. mil., 1879, vol. 35, p. 279. 

6 Oldright: Canada Journ. Med. Sci., 1881, vol. 6, p. 79. 

7 Read : Phil. Med. News, 1883, vol. 42, p. 241. 

8 Parkinson, N. Y. Med. Record, 1886, vol. 29, p. 442. 

9 Bryant: Surgery, 3d Am. ed., pp. 807 and 934. 

10 Erichsen : Surgery, Am. ed., p. 440. 

11 Shaw: Patholog. Soc. London, 1848-50, p. 125. 



504: DISLOCATIONS OF THE FIBULA. 

and had become ankylosed in its displaced position." The dislocation is 
not always upward, but is sometimes forward, and sometimes the head 
has been freely movable backward and forward. 

1. Forward. — The reported cases are those of Jobard, Savournin, 
Thomson, Melzer, Robert, and Read. Jobard's patient, a man thirty 
years old, stumbled and fell while going upstairs, and felt a sort of snap 
before he had fallen to the ground ; Savournin's patient, a woman, thirty- 
five years old, while descending a staircase, caught her heel on a step ; 
the front of the foot was sharply depressed and turned inward, and she 
fell in a squatting posture. Thomson's patient fell into a ditch, striking 
upon the injured leg ; Melzer's slipped sidewise, and Robert's while 
jumping over a bench fell with the foot flexed and inverted, and suffered 
much pain all along the outer side of the leg, especially at the lower part. 
Read's patient, while shoeing a horse, was thrown down with his leg 
doubled under him. The mode and mechanism of production are not 
clear, although they seem to be directly associated with forcible depression 
and inversion of the front part of the foot. Jobard was inclined to 
attribute the displacement to the contraction of the muscles of the foot 
that arise from the front of the fibula, and Malgaigne regarded the expla- 
nation with favor, but it is open to serious objection. 

Jobard's patient could flex and extend the leg, but could not rest his 
weight upon it ; Melzer's could flex the knee and foot to a right angle, 
but the movements were painful; in Robert's the leg was slightly flexed 
and the foot everted, and extension of the knee and adduction of the foot 
were painful. In Read's the leg was extended, and the patient was in 
much pain. In Robert's there was much tenderness on pressure at the 
external malleolus, but no lesion was recognizable there. 

The head of the fibula can be felt as a marked prominence in front of 
its normal position, forward and outward in Read's, three centimetres 
nearer the anterior tuberosity of the tibia in Robert's, and in Jobard's 
and Robert's it is noted that the tendon of the biceps could be plainly 
felt curving forward to the fibula. 

Reduction was effected by Thomson, Jobard, and Robert by direct 
pressure upon the head of the fibula, while the knee was partly flexed ; 
Savournin reduced while the knee was extended and the foot held in 
such a position that the anterior muscles of the leg were relaxed ; in 
Read's case reduction took place spontaneously during the struggles of 
the patient while being anaesthetized. All recovered full use of the limb. 

2. Backward. — The reported cases are those of Dubreuil, Richardson, 
Erichsen, Oldright, and Parkinson. Dubreuil's patient, a man thirty- 
two years old, in jumping to save himself from a fall, contracted his 
muscles forcibly and abducted his right leg ; he felt sharp pain at the 
head of the fibula, and it was found to have been displaced an inch back- 
ward. Richardson's patient, a boy nine years old, fell from a fence and 
was thought to have struck the head of the fibula in the fall ; Oldright's, 
a boy two years old, fell from a chair ; Erichsen 's, a man twenty-three 
years old, fell while walking, with the leg bent under him, so that he 
came down in a sitting posture ; Parkinson's, a man of twenty-four years, 
fell on the injured side while walking. In Dubreuil's, Erichsen's, and 
Parkinson's cases it seems reasonable to attribute the displacement to the 



DISLOCATIONS OF THE FIBULA. 505 

forcible contraction of the biceps, but in Olclright's and Richardson's the 
patients were so young that the intervention of direct external violence 
is probable. In a case observed by myself (Fractures, p. 586) compli- 
cated by fracture along the epiphyseal line, direct violence was the cause. 

In Dubreuil's and Richardson's cases the foot was slightly everted, 
and in the former there was a sensation of cold and numbness along the 
peroneal region of the leg. In Parkinson's the external lateral ligament 
could be distinctly felt ; in Erichsen's the fendon of the biceps was tense, 
and in Richardson's it could be distinctly felt still attached to the fibula. 
The displacement is described as backward in all, and its extent as one 
inch in Dubreuil's. 

Reduction was effected without much difficulty by Dubreuil, Richard- 
son, and Parkinson by direct pressure upon the head of the fibula while 
the knee was flexed. In Dubreuil's the displacement recurred on the 
following day, and was then less easily reduced ; a knee-cap of leather 
was then worn for twelve days, and the patient was then able to walk 
with a cane, but for some time the leg had a tendency to bend outward ; 
ultimately recovery was complete, as it was also in the other two cases. 

Erichsen and Oldright did not see their patients until some time after 
the accident ; in the former's the displacement was permanent and " the 
limb was somewhat weakened, so that the patient could not jump, but 
otherwise he suffered no inconvenience." In Oldright's the displacement 
could be easily reduced, but it immediately recurred ; local pressure and 
immobilization of the knee failed to cure. Judging from my experience 
with dislocations of the outer end of the clavicle, I should think that 
retention by a strip of adhesive plaster placed around the upper part of 
the leg would be effective. 

3. Uptvard. — Of this form there are only three reported cases, Boyer, 
Stoll, and Sorbets, and the account of the latter is too incomplete to be 
of any use or even to establish the accuracy of the diagnosis. 

Boyer's patient appears to have received a dislocation outward of the 
foot or a Pott's fracture of the ankle in which the fibula, instead of 
breaking, had been pushed bodily upward ; the extent of the displace- 
ment is not stated ; the restoration of the foot to its place corrected the 
upper dislocation also, and the patient recovered. A somewhat similar 
case in which there was fracture of the lower end of the tibia is quoted 
in Fractures, p. 580. 

In Stoll's case the head of the fibula is described as standing " notabl} x 
higher than normal on the outer surface of the tibia, and forming there 
an immovable, firm, sharply projecting tumor, very painful on pressure." 
He quotes Dubreuil's case as identical, and attributes the displacement 
to the forcible contraction of the biceps, and, therefore, it seems possible 
that the dislocation may belong among the backward ones. The patient 
was a circus-rider and received the injury in jumping from his horse, 
alighting upon his toes. The sole was everted, the toes abducted ; the 
inner side of the ankle swollen and tender ; passive motion of the knee 
and ankle very painful ; numbness of the outer side of the leg. No 
fracture could be found. Reduction was made by forcible traction on 
the foot, the knee being flexed at a right angle, and was accompanied by 
a snapping sound. 






506 DISLOCATIONS OF THE FIBULA. 

4. Outward. — The only case in which the displacement is described 
as outward is one briefly referred to by Bryant, in which the displace- 
ment was due to arrest of the growth of the tibia following injury to its 
epiphyseal cartilage. 

B. Dislocations of the lower end. 

Of this the only two recorded cases, excluding, of course, the numerous 
ones in which diastasis of this joint has formed one of the lesions of Pott's 
fracture at the ankle and the few cases in which the same diastasis has 
been part of inward or outward dislocation of the foot, are one observed 
bj Nelaton in the service of Gerdy and one in the service of Tillaux 
reported by Dunand. 1 Gerdy's patient came to the hospital thirty-nine 
days after the accident. The wheel of a wagon had passed across the 
lower end of his leg and had forced the external malleolus so far back- 
ward that it was almost in contact with the outer border of the tendo- 
Achillis ; the outer surface of the astragalus could be felt through almost 
its entire extent. The patient walked fairly well, and Gerdy thought no 
attempt to reduce should be made. 

Tillaux's case resembles Pott's fracture at the ankle. The patient in 
stepping from an omnibus caught his foot and fell forward. The foot was 
everted, there was a large ecchymosis on the inner side of the leg and 
foot, and another on the outer side ; the ankle was swollen and tender, 
especially on the inner side ; no fracture could be found. The lower end 
of the fibula was freely movable forward and backward with cartilaginous 
crepitus, and could be drawn outward so far that the end of the finger 
could be inserted between it and the astragalus. The patient made a 
good recovery. It seems probable that this was produced by inversion 
of the foot, by which the upper outer border of the astragalus was turned 
outward, forcing the fibula away from the tibia. 

Spontaneous or Pathological Dislocations. 

These have been reported as occurring at the upper end in consequence 
of inflammation of the joint, of rachitic changes' in the bones, and of 
exaggerated growth of the tibia following necrosis. In the same group 
may be classed the dislocation outward reported by Bryant, and quoted 
above, which was due to arrest of the growth of the tibia. 

Malgaigne, after quoting a general description given by Cooper, accord- 
ing to which chronic hydrarthrosis leads to the easy displacement of the 
head of the fibula and to much weakness and fatigue in walking, describes 
a case under his own care in which this laxity of the joint existed; in 
certain movements of the knee the fibula was displaced backward, return- 
ing almost at once to its place with a cracking sound ; the condition 
followed an arthritis which had produced a similar relaxation of the knee. 

In a case of rachitic curvature of the leg in an infant Malgaigne thought 
he could recognize the head of the fibula displaced upward almost to the 
level of the aiticular surface of the tibia, and on examining the rachitic 

1 Dunand : These de Paris, 1878, No. 217. 



SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS 



507 



skeletons preserved in the Musee Dupuytren he found several examples ; 
the displacement was upward and outward at the upper end, the lower 
end preserving its normal relations. 

Dislocation downward of the upper end due to elongation of the tibia 
following necrosis was described by Parise (quoted by Malgaigne), who 
reported three cases. In one of them the elongation was three centi- 
metres on the inner side of the tibia and one and a half centimetres on 
the outer. Malgaigne subsequently saw 'and reported a fourth case. 
The condition did not affect the functions of the limb. 



CHAPTEE XXXI. 

DISLOCATIONS AT OR NEAR THE ANKLE. 

1. DISLOCATIONS OF THE FOOT. 2. SUBASTRAGALOID DISLOCATIONS. 
3. DISLOCATIONS OF THE ASTRAGALUS. 4. MEDIO-TARSAL DISLO- 
CATIONS. 

Anatomy. — The principal movements of the foot are those of flexion 
and extension, or dorsal and plantar flexion, which take place in the 
joint formed by the astragalus and the tibia and fibula, and that of adduc- 
tion and abduction combined, respectively, with inversion and eversion 
of the sole, which takes place in the joints between the astragalus on one 
side, and the calcaneum and scaphoid on the other, and is aided by slight 
motion between the calcaneum and cuboid. The axis of the first joint, 
the ankle, is horizontal and nearly transverse, its inner end inclining 
forward ; that of the other runs obliquely from a point near the inner 
tuberosity of the calcaneum upward and forward to a point on the upper 
surface of the neck of the astragalus. 

The astragalus articulates above with the under surface of the tibia, 
and on the sides with the malleoli, between which it is so snugly placed 
that no lateral motion is possible. On each side the lateral ligament 
passes to the astragalus and calcaneum from the malleolus, and the lower 
ends of the tibia and fibula are bound together bv ligaments in front and 
behind. The capsule, which is attached close to the edge of the articular 
cartilage on each bone, is loose in front and behind. The range of dorsal 
and plantar flexion is nearly 90°, and as the articular surface of the 
astragalus is somewhat narrower behind than in front some lateral motion 
of the joint is possible in full plantar flexion. 

The rounded head of the astragalus articulates with the posterior con- 
cave surface of the scaphoid, the inferior calcaneo-scaphoid ligament, 
and slightly with the anterior end of the calcaneum. On the under sur- 
face of the astragalus are two articular facets corresponding to two on the 
upper surface of the calcaneum, and between them is the strong interos- 
seous ligament which fills the canal formed by grooves separating the two 
articular surfaces on each bone, and binds the bones firmly together. 
The maximum range of motion in these joints is about 40°, and is limited 
partly by bony contact and partly by the ligaments. 

In this chapter I shall describe four different dislocations : those of the 
foot, those of the astragalus, the subastragaloid, and the medio-tarsal dis- 
locations ; under the first term are included those in which the astragalus, 
while maintaining its relations with the other bones of the foot, is dis- 
placed from the bones of the leg; under the second, those in which it is 
also displaced from the calcaneum and scaphoid ; under the third, those 
n which the astragalus remains in the tibio-fibular mortise, and is sepa- 



DISLOCATIONS OF THE FOOT. 509 

rated from the calcaneum and scaphoid ; and in the fourth, those in which 
the scaphoid and cuboid are together dislocated from the astragulus and 
•calcaneum. 

1. Dislocations of the Foot. Tibio-tarsal Dislocations. 

The displacements of the astragalus and the foot are so complex that 
the nomenclature of the various dislocations presents serious difficulties, 
and the confusion has been increased by the varying practices of different 
writers, some of whom treat the tibia as the dislocated bone and apply the 
terms indicative of direction to it, while others consider the foot as the 
dislocated portion. I shall here follow the latter practice, and shall use 
in the classification only four main terms, dislocations forward] backward, 
outward, and inivard, disregarding for the moment the many deviations 
in the direction of the toes and of the sole which are seen in conjunction 
with the principal dislocations. Of these four the first two are pure 
dislocations ; in the latter two are frequently placed cases in which the 
displacement is associated with fracture of one or both bones of the leg, 
and of which the more common forms have been elsewhere described 
among fractures at the ankle. It must be freely conceded that the classi- 
fication, especially in respect of the last two groups, is arbitrary and 
open to serious criticism, but so are all others that have been proposed, 
and it is believed that this one has a sound clinical basis in so far that 
the terms outward and inward correspond to displacement outward or 
eversion, or to displacement inward, or inversion of the foot, symptoms 
which would at once attract the attention of the surgeon, and that its 
divisions coincide also with those of the modes of production. 

Two striking varieties, in which the toes are turned directly inward 
or outward, will be mentioned under inward and outward dislocations 
respectively. The latter has been classified by some as a separate form, 
under the title of dislocations of the foot by rotation outward. 

The mechanism of the joint and the mode of production of the disloca- 
tions have been experimentally studied by many surgeons and anatomists, 
of whom I shall here name only one of the more recent, Honio-schmied, 1 
whose experiments were exceptionally numerous, and whose article is 
very full. 

A. Dislocations backivard. 

(Syn. Dislocations of the lower end of the tibia forward.) 

In these dislocations the astragalus, and with it the foot, is displaced 
backward to a variable distance, with rupture of the lateral ligaments 
and sometimes of other parts of the capsule, and sometimes with fracture 
of one or both malleoli or of the posterior edge of the lower articular 
surface of the tibia. 

The cause is usually extreme plantar flexion of the foot, in which the 
posterior border of the end of the tibia comes into contact with the poste- 
rior, lip of the astragalus (Henke 2 ), by which a new centre of motion is 

1 Honigschmied: Deutsche Zeitschrift fur Chir., 1877, vol. 8, p. 239. 

2 Henke: Zeitschrift fur rat. Med. 1858, 3d ser., vol. 2, p. 177. 



510 DISLOCATIONS AT OR NEAR THE ANKLE. 

established behind the line of the malleoli ; the continuation of the move- 
ment ruptures the lateral and the anterior ligaments, and the bones being 
thus freed the tibia is pushed forward over the astragalus, or the foot is 
pushed backward under the tibia, according as the causative violence acts 
upon the leg or upon the foot. The rupture of the ligaments is the first 
step, and the fixation of the astragalus behind the tibia takes place by 
correction of the plantar flexion. Commonly the injury is produced by 
a fall backward while the foot is fixed. In an incomplete dislocation 
reported by Sanson (quoted by Albert) the patient's leg was bent under 
him in a fall in such a way that the dorsum of the foot and the front of 
the leg rested on the ground, and the buttocks rested on the heel ; in 
this case the mechanism appears to have been pure exaggerated plantar 
flexion. Examples of pure primary dislocation are rare, Malgaigne 
could find only 18 reported cases; but partial, and perhaps complete, 
dislocations occurring as a secondary result of rupture of the lateral liga- 
ments or fracture of the fibula and internal malleolus, as in Pott's fracture 
at the ankle, are frequent, and always need to be guarded against in the 
treatment of this last-named injury ; they are produced either by the 
falling backward of the insufficiently supported foot, as the patient lies 
upon his back, or by contraction of the flexor muscles, and occasionally 
subcutaneous division of the tendo-Achillis has been resorted to to over- 
come or prevent it. 

Honigschmied produced the dislocation 20 times and found the results 
quite constant ; in 14 the internal lateral and the anterior branch of the 
external lateral ligament were the first to yield, being torn away from 
their insertions, then the middle and posterior branches of the external 
lateral ligament yielded, and the foot was thus completely freed. The 
ligaments were torn away, and occasionally small scales of bone came 
away with them. In 5 experiments on the bodies of elderly people, both 
malleoli were broken off in 3, and the external malleolus in 2. The 
internal malleolus broke at its base, and the line of fracture ran down- 
ward and backward ; that of the external malleolus ran upward and 
backward, beginning just above the insertion of the anterior branch of 
the lateral ligament. 

Clinically and post-mortem the same lesions have been found ; fracture 
of the external malleolus is common, that of the internal malleolus and 
of the posterior articular border of the tibia is occasionally seen. In a 
case reported by Malgaigne of this fracture of the tibia the posterior 
fragment comprised the posterior half of the articular surface and ex- 
tended an inch upward on the back of the bone. 

The foot appears shortened in front, and the heel lengthened, to an 
extent that varies with the degree of the displacement, the maximum 
being about an inch ; the lower end of the tibia projects more or less 
markedly in front and sometimes is exposed by rupture of the skin ; the 
extensor tendons may be felt as tense cords crossing to the dorsum of the 
foot, and the tendo-Achillis curves backward to the heel leaving on each 
side a well-marked depression between itself and the malleolus. The 
toes may be a little depressed, and perhaps abducted or adducted. If 
the fibula is broken its malleolus accompanies the foot in its displacement 
backward. 



DISLOCATIONS -OF THE FOOT. 511 

Reduction, with the exception of Cooper's first case, in which he appears 
not to have made the diagnosis at the time, has always been easily obtained 
by pressing the foot forward and the lower end of the leg backward. 
Malgaigne recommends that the foot should be held in dorsal flexion 
while the pressure is made, but others, and, I think, more justly, prefer 
plantar flexion because the foot is in that position when dislocation takes 
place. Prevention of recurrence appears to have been difficult ; Mal- 
gaigne quotes several cases in which the treatment failed and the patients 
remained crippled. In his own last case he was successful by immobiliz- 
ing the limb in a mould of plaster, and there seems to be no reason to 
doubt that a firm dressing of gypsum or silicate bandages would fully 
meet the indication. I have always found it satisfactory in cases of Pott's 
fracture in which the foot tended to sink backward. 

If the dislocation is compound it must be treated antiseptically in the- 
most rigorous manner, and with drainage behind as well as in front of 
the joint. 

The disability in cases that remain unreduced is very great and may 
call for excision or amputation. It is worthy of note that Hueter success- 
fully reduced by plantar flexion and direct pressure a dislocation that had 
existed for six months. 

B. Dislocations forward. 
(Syn. Dislocations of the lower end of the tibia backward.) 

In this dislocation, which is much rarer than the preceding, the 
astragalus, and with it the foot, is displaced forward from beneath the 
tibia. Malgaigne collected only 5 cases, Delamotte, Colles, Nelaton, 
Pierre, and R. W. Smith, and I am able to add only 5 more, Huguier, 1 
Sarazin, 2 Augarcle, 3 Willemin, 4 and Hornby, 5 making 10 in all. 

The mode of production may be by dorsal flexion of the foot followed 
by impulsion of the tibia downward and backward by a force acting in 
the direction of its long axis, or by direct pressure of the foot forward 
and of the leg backward while they are at right angles to each other. 
Among the recorded cases are clear examples of each, such as R. W. 
Smith's and Nelaton's of the former, and Huguier's of the latter. R. W. 
Smith's 6 patient, while standing with the hip and knee flexed and with 
the foot restinD- on a stone in such a manner that the toes were higher 
than the heel, was struck upon the knee by a falling cask which forced it 
downward and increased the flexion at the knee and ankle. In Nelaton's 7 
case, a woman, who fell from the fourth floor, the anterior lip of the 
articular surface of the tibia was broken off, and the upper surface of the 
astragalus was scratched antero-posteriorly, showing that the tibia had 
been inclined forward so that the edge of the fracture was in contact with 

1 Huguier : Gaz. des Hopitaux, 1855, p. 469, and Arch. gen. de Med., 1868, i. p. 513. . 

2 Sarazin : Eecueil de mem. de med, chir. et pharm. mil., 1860, vol. 4, p. 66. 

3 Augarde: Idem., 1880, vol. 36, p. 168. 

* Willemin : L'Union med., 1866, vol. 29, pp. 50 and 73. 

5 Hornby: Med. Times and Gazette, 1871, ii. p. 10. 

6 K. W. Smith: Dublin Quart. Journ. of Med., 1852, i. p. 465. 

7 Nekton : Pathol. Externe, vol. ii. p. 477. 



512 DISLOCATIONS AT OR NEAR THE ANKLE. 

the astragalus and had been pressed firmly against it as the tibia slipped 
backward. 

The experiments of Henke and Honigschmied indicate that dorsal 
hyperflexion alone is not competent to produce the dislocation or even to 
rupture both lateral ligaments. They both found it necessary to divide 
the tendo-Achillis before the flexion could be carried far enough to rupture 
any of the parts of the joint, and even then the injury was usually limited 
to fracture of the internal malleolus and rupture of the posterior branch 
of the external lateral ligament. It is probable, therefore, that the real 
mechanism in cases like the two just quoted is the violent driving of the 
tibia dowmward and backward while the knee is bent forward over the 
foot. 

The second method of production differs, therefore, from the first only 
in the direction in which the force and counter-force are applied, both 
acting, in the second, at right angles to the long axis of the limb, the one 
upon the front of the lower end of the tibia, the other in the opposite 
direction upon the back of the heel. Huguier's case is an example : a 
man, while engaged in turning a railway turntable, fell and caught his 
foot in such a manner that the knee was fixed and a projecting rail on 
the moving turntable pressed against the front of the tibia six inches 
above the ankle and produced a well-marked dislocation of the foot for- 
ward. In the case reported by Willemin the mechanism was probably 
the same ; a woman slipped with her left foot and fell, and in the fall 
struck the heel of the right foot upon the floor, dislocating it forward ; 
she had previously suffered dislocation of several other joints by compara- 
tively slight violence, and probably her ligaments were relaxed or weak. 
In Hornby's it was also probably the same ; the patient had his foot and 
leg caught under a falling horse ; and in Augarde's the dislocation was 
caused by a violent movement of the patient in an effort to rise from the 
floor while his foot was caught between two iron bars ; apparently the 
knee was thrust forward while the foot was fixed and the front of the 
lower part of the leg rested against one of the bars, and thus the extreme 
lower end of the bone was carried behind the astragalus. In Sarazin's 
the cause appeared to have been a fall upon the feet, but the patient was 
not seen until three months after the accident, the displacement forward 
was only one centimetre, the external malleolus had been broken, and the 
intermalleolar space was widened ; the articular surface of the astragalus 
could not be felt in front of the tibia. 

The symptoms are lengthening of the front of the foot and shortening 
of the heel, with effacement of the depressions on each side of the tendo- 
Achillis. The foot is in the position of more or less plantar flexion, 
and in one or two cases the hollow of the instep was exaggerated. The 
upper articular surface of the astragalus can be felt in front of the end of 
the tibia, and the malleoli are nearer to the heel and to the sole than 
normal. 

In Huguier's, Willemin's, Hornby's, and Augarde's cases reduction 
was easily made by traction and direct pressure ; in Smith's it could not 
be made, but there is reason to think the efforts were not guided by a 
correct appreciation of the nature of the injury ; Nelaton's patient was 
killed by the fall ; in the remaining cases the details of treatment are 



DISLOCATIONS INWARD. 513 

lacking. In Smith's, Colles's, Pirrie's, and Sarazin's cases the disloca- 
tion was not reduced, and the patients were much crippled. 

C. Dislocations inward. 

In this division are placed those cases in which, usually by adduction 
and inversion (supination), the foot is moved downward and to the inner 
side, so that the astragalus leaves the tibio-fibular mortise more or less 
completely. Two distinct forms are observed : in one the foot is markedly 
inverted and the upper surface of the astragalus can be seen and felt 
raising the skin under the external malleolus ; in the other the inversion 
of the foot is less or is absent and there is marked adduction, so that 
sometimes the ends of the toes point directly inward ; in the latter form 
it is thought that the displacement is secondary to a backward dislocation. 

Malgaigne includes in the group (which he terms tibio-tarsal disloca- 
tions outward) many cases complicated by fracture of the astragalus or 
of one or both bones of the leg ; but of his total of 22 cases, 8 were not 
thus complicated, and to these I can add 4, Busch, 1 Nunnely, 2 Eames,' 
and Carmichael. 4 I have described under " fractures by inversion and 
adduction of the foot/' Fractures, p. 578, the lesions and symptoms in 
cases in which fracture is present and the displacement is absent or 
slight. 

Excluding for the moment those cases in which the displacement is 
secondary to a backward dislocation, it seems probable that the cause is 
violent supination, or inversion, of the foot, but the histories of the cases 
do not positively establish this opinion. In most the cause has been a fall, 
usually from a height ; Carmichael' s patient, a woman, turned her foot 
while walking down hill, Nunnery's ran at night into an excavation the 
bottom of which was covered with loose stones and bricks, Eames's fell 
w T ith a falling platform, and Busch's was injured in the overturning of a 
wagon. 

The astragalus fits so snugly and squarely into the tibio-fibular mortise 
that in a considerable proportion of cases it cannot be turned in it about 
its own antero-posterior axis without breaking the external malleolus or 
forcing it away from the tibia by the pressure of the upper outer edge of 
the astragalus. In the experiments which Honigschmied made by fixing 
the foot in a vise and bending the leg directly toward the inner side — 
tibial flexion — the external malleolus was broken 5 times, the external 
lateral ligament torn from its insertion 12 times, and in 3 cases the joint 
remained unopened and separation took place between the astragalus and 
the calcaneum. These results coincide in the main with those obtained 
in a similar manner by Bonnet, and Honigschmied accepts the latter's 
opinion that the fracture of the malleolus is effected by the direct pressure 
upon it of the outer upper border of the astragalus and not by traction 
exerted through the external lateral ligament. Bonnet frequently found 
the internal malleolus also broken, Honigschmied never. 

1 Bus2h : Lehrbuch der Chir., vol. 2, part 3, p. 327; quoted by Lossen. 

2 Nunnely: Brit. Med. Journ., 1868, ii. p. 362. 

3 Earnes: Idem, 1871, i. p. 503. 

4 Carmicbael: Idem, 1871, ii. p. 35. 

33 



514 DISLOCATIONS AT OR NEAR THE ANKLE. 

In one case, Busch, in which there was no fracture, the dislocation 
was compound and the bones of the leg protruded through the wound in 
front, the astragalus lay entirely to the inner side of the internal mal- 
leolus, and the foot was greatly adducted ; Busch thought the dislocation 
had been primarily backward. In Bardy's fracture of the fibula was 
noted, and in Ravaton's (both quoted by Malgaigne) there was diastasis 
of the lower tibio- fibular joint, which gave him much trouble in the 
treatment. 

In some cases, in which the displacement inward may be assumed to 
have been secondary to" a backward dislocation, the adduction of the foot 
has been very great, 90°, so that the toes pointed directly toward the 
other ankle ; in the others the adduction is less, but the inversion is 
great ; in Carmichael's " the plantar aspect pointed to the middle line of 
the body," in Eames's "the plantar aspect of the foot was completely 
inverted." In some the external malleolus was very prominent; in 
Nunnery's " there was a large and well-marked projection below the 
outer malleolus" over which the skin was very tense, and "there was a 
deep, narrow depression at the inner malleolus where the skin was also 
very tight." 

Reduction has always been easily effected by traction and eversion of 
the foot, and in the uncomplicated cases the recovery has been complete. 

D. Dislocations outward. 

The injuries which have been described under this head are, almost 
without exception, those which are now commonly known as Pott's 
fracture at the ankle, and which have been described in Fractures, page 
581, as fractures by eversion and abduction of the foot. A few more or 
less doubtful cases have been reported which differ more or less from 
those of Pott's fracture in their mode of production and lesions, and 
which might be termed partial dislocations of the foot outward. One 
such, Boyer, has been quoted in Chapter XXX., page 505, as an ex- 
ample of upward dislocation of the head of the fibula ; another is that of 
Desault, quoted by Malgaigne (loc. cit., pp. 996 and 998), in which the 
cause appears to have been abduction of the foot without eversion. 

In three cases, Huguier, 1 Thomas, 2 and Soubie, 3 the foot has been so 
far a,bducted that the toes pointed directly outward. This form was first 
observed by Huguier and described by him as "dislocation of the foot by 
rotation outward." His patient was overthrown by a cask, which rolled 
upon his legs ; Thomas's by a falling mass of straw ; and Soubie's fell 
from a height of six feet, alighting upon his left foot, which was then 
engaged between a large stone and the trunk of a vine, while the body 
was twisted to the right, and the patient fell on his right side. In 
Huguier's case the external malleolus was separated from the tibia, 
pressed backward, and rotated outward, and the shaft of the fibula was 
broken in the upper third. In the other two cases no fracture was found. 
In Thomas's " the anterior border of the low T er end of the tibia formed a 

1 Huguier: L'Union Medicale, 1848, p. 128. 

2 Thomas: Revue de Chirurgie, 1887, p. 821. 

3 Soubie, quoted by Thomas. 



COMPLICATED DISLOCATIONS OF FOOT. 515 

marked prominence in front over which the skin was tightly stretched, 
and below which was a transverse depression that would admit the finger." 
Reduction was easily effected under anaesthesia in all three cases. 

Nelaton made a separate class of those rare cases of Pott's fracture in 
which the astragalus is forced upward between the tibia and fibula, and 
termed them dislocations upward. I do not see that any advantage is 
to be gained by separating them from the group of which they are only 
an extreme form. 

The principles of treatment are the same as in Pott's fracture. 

E. Compound and complicated dislocations of the foot. 

Dislocations of the foot may be compound, primarily or secondarily, 
with protrusion of the bones of the leg or of the astragalus through the 
wound, and they may be complicated by rupture of bloodvessels and by 
other fractures than those of the malleoli already referred to. 

In dislocations that are primarily compound the wound of the skin may 
be made from within outward by the projecting bone or by contact with 
the ground. In those that become secondarily compound the sloughing 
of the soft parts may be due to the pressure of the unreduced bones or 
to bruising of the soft parts inflicted at the time of dislocation. 

The statistics that have been collected come almost entirely from the 
period anterior to the introduction of antiseptic methods and therefore 
cannot be trusted to show the necessity or desirability of amputation or 
excision. So far as can be judged from recent experience in these dis- 
locations and in compound dislocations of other joints, conservative 
treatment under antiseptic rules may properly be tried in primary com- 
pound dislocations not seriously complicated by fracture, and if suppura- 
tion is avoided a useful, movable joint may be hoped for. Particular 
. attention must be given to drainage, and as the astragalus completely 
fills the space between the malleoli separate drainage must be provided 
for the back and front of the joint. The limb must be carefully immo- 
bilized with the foot at a right angle to the leg and without inversion or 
eversion, in order that if the joint should become stiff the disability will 
not be increased by a faulty position of the foot. 

In cases in which suppuration has ensued, either before or after reduc- 
tion, the treatment should still be conservative with the object of obtaining 
ankylosis in a good position or perhaps a slightly movable joint ; but if 
the astragalus is broken I think it would be better to remove it. It has 
frequently happened that suppuration of the joint has been followed by 
necrosis of the astragalus, presumably because of the interruption of its 
blood-supply consequent upon the laceration of its ligaments, and this 
result would of course be still more probable after its fracture. Langen- 
beck 1 even in 1874 recommended conservative treatment in compound 
injuries of the ankle, both in civil and military practice, although Billroth 
and Socin estimated the mortality after such injuries under all kinds of 
treatment at 31 and 38 per cent, respectively. I have had no experience 
with compound dislocations of the ankle, but all the compound fractures 

1 Langenbeck: Arch, fur klin. Chir., 1874, vol. 16, p. 484. 



516 DISLOCATIONS AT OR NEAR THE ANKLE. 

involving the joint that have come under my care, nine or ten in number, 
have, with one exception, recovered without suppuration, and although 
the laceration of the soft parts is less in such injuries than it is in the 
complete dislocations I believe that primary amputation or excision 
should not be resorted to in the absence of exceptional conditions, such 
as extreme laceration or fracture, that specially indicate one or the other. 

2. SUBASTRAGALOID DISLOCATIONS. DISLOCATION OF THE ASTRAGALO- 
CALCANEOID AND THE ASTRAGALO-SCAPHOID JOINTS. 

For the establishment of this group in the classification of dislocations 
of the tarsal bones we are indebted to Broca, 1 who, in a remarkable paper 
read before the Societe de Chirurgie in 1852, carefully analyzed the 
scattered cases that had been reported under various titles and gave a 
detailed and systematic description of the various forms of the injury to 
which little has since been added except in amplification of the statistics. 
His plan of subdivision recognized dislocations backward, inward, and 
outward of the calcaneum and scaphoid from the astragalus. Malgaigne 
added a fourth variety, dislocations forward, of which Broca himself 
subsequently saw a possible example, and changed the nomenclature 
by treating the astragalus as the dislocated bone and applying the terms 
indicative of the direction of the displacement according to its position 
with relation to the others. I shall here follow Broca's use of the terms, 
which is in harmony with that used in the other dislocations. 

The dislocation, then, presents four varieties : that in which the 
calcaneum and scaphoid are displaced inward (and somewhat backward), 
the head of the astragalus projecting on the outer part of the dorsum of 
the foot ; that in which they are displaced outward ; and those in which 
they are displaced directly forward or backward and downward. The 
first two are about equal in frequency and together comprise most of the 
reported cases ; of each of the last two only one or two examples have 
been reported. The most notable addition to the collected statistics has 
been made by Poinsot. 2 

A. Dislocations inward, or inward and backward. 

The cause is forcible inversion and adduction of the foot, usually com- 
bined with violence acting in the direction of the long axis of the leg, 
as in a fall from a height. The displacement is rarely, if ever, directly 
inward, but is also somewhat backward, so that the head of the astra- 
galus rests partly upon the cuboid. The only autopsy is one made in an 
old case by Quenu ; 3 there was shortening of the dorsum of the foot, 
and elongation of the heel, and the foot was in the position of varus. 
The head of the astragalus lay upon the interarticular lines between the 

1 Broca: Mem. de la Soc. de Chirurgie, 1852, vol. 3, p. 566, and abstract in Bull, 
de la Soc. de Chirurgie, 1853, vol. 3, p. 241. 

2 Poinsot: L'intervention chirurgicale dans les luxations compliques du cou-de- 
pied, Paris, 1877, and his translation of Hamilton's Fractures and Dislocations, p 
1196. 

3 Quenu: Progres Med., 1883, p. 187. 



SUBASTRAGALOID DISLOCATIONS 



517 



calcaneum and cuboid and the cuboid and scaphoid, overlapping the 
former half an inch and thus resting on the cuboid. The posterior 
border of the astragalus lay in the groove between the anterior and 
posterior superior articular surfaces of the calcaneum, and its posterior 
lip had been broken off and remained in its normal relations with the 
calcaneum. There was no fracture of either malleolus. The dorsalis 
pedis artery and the extensor tendons lay to the inner side of the head 
of the astragalus ; the peroneal tendons had been displaced from their 
groove and separated half an inch from the fibula. In other cases the 
displacement has been greater and the skin has been broken on the outer 
side of the foot ; in one of Malgaigne's the head of the astragalus was 
almost in contact with the fifth metatarsal bone; in one of Letenneur's it 
corresponded to the outer border of the foot and projected entirely through 
a wound in the skin, and the calcaneum had been completely displaced 
from its inferior articular surface. The form and degree of the displace- 
ment vary with the different combinations of displacement inward, back- 




Fig. 162. 



)54 




The same ; 1, head of astragalus ; 3, 4, old cicatrices ; 5, 
fistula ; H, fracture of the fibula. (Dr Borne. ) 



ward, and by adduction of the front of 
the foot, the latter sometimes leaving the 
posterior part of the calcaneum less dis- 
placed inward than its front part. With 
the dislocation there is sometimes asso- 
ciated injury to the calcaneo-cuboicl joint, 
rupture of its ligaments and partial dislo- 
cation of the bones. 

The symptoms are more or less short- 
ening of the dorsum of the foot and lengthening of the heel, adduction 
of the toes, and elevation of the inner border of the foot ; prominence of 
the tip of the external malleolus and of the head of the astragalus on the 
outer side of the dorsum, with marked depressibility of the soft parts 
below each ; the internal malleolus is deeply placed under the skin, and 
below and behind it can be felt the projecting sustentaculum tali, and in 
front of it the inner surface of the scaphoid. 



Subastragaloid dislocation inward 
5, sustentaculum tali ; -i, inner malle 
olus. tDc Bourg.) 



518 



DISLOCATIONS AT OE NEAR THE ANKLE, 



Fig. 163. 



B. Dislocations outward. 

Of this Malgaigne makes two varieties, distinguished clinically by the 
existence of marked abduction of the toes in one, and its absence in the 
other. In the former (his luxation oblique en dedans, or obliquely out- 
ward, according to the nomenclature here used) the posterior articular 
surface of the astragalus is not separated from the calcaneum, but the 
foot has turned upon the posterior calcaneo-astragaloid joint, or upon the 
outer part of the interosseous ligament as a centre, and the scaphoid has 
been carried to the outer side of the head of the astragalus, and also 
sometimes either upward or downward. In the second form, that without 
abduction of the toes, the foot is displaced bodily outward from beneath 
and in front of the astragalus. The cause in the former is the forcible 
abduction of the foot; in the latter it appears to be either abduction and 
eversion of the foot, or great violence exerted directly against the inner 
side of the foot, or the outer side of the lower part of the leg. The dislo- 
cation may be primarily or secondarily compound, the wound in the skin 
corresponding to the head of the astragalus, which may project entirely 
through it. The tendon of the tibialis anticus sometimes lies along the 
inner and upper part of the neck of the astragalus, which is thus tightly 
held between it and the calcaneo-scaphoid ligament. In a case of the 
oblique form quoted by Malgaigne, in which the 
patient died four days after the accident, the 
outer part of the interosseous ligament in the 
sinus tarsi was entire ; the inner part was rup- 
tured. In one of the complete outward form, of 
which the specimen was dissected, and reported 
by Nelaton 1 (Fig. 163), the head of the astragalus 
rested against the inner side of the scaphoid, and 
its posterior lip was engaged in the groove in the 
upper surface of the calcaneum ; the lower part 
of the internal lateral ligament, the interosseous 
ligament, and the astragalo-scaphoid ligament 
were ruptured, and the posterior and outer part 
of the external malleolus was broken. 

The calcaneo-cuboid joint may also be injured, 
and the bones partly displaced from each Other. 

The symptoms in the oblique variety are the 
marked abduction of the foot, more or less ever- 
sion, and marked prominence of the head of the 
astragalus on the inner side. In a case reported 
by Boyer the displacement was slight, and was at 
first overlooked ; when recognized, it was irre- 
ducible, but the patient regained good use of the 
limb. 

The symptoms in the variety in which the dis- 
placement is directly outward are the marked 
displacement of the foot, with but little, if any, 
eversion or abduction, the axis of the leg falling to the inner side, and 

1 Nelaton : Bull, de la Soc. Anatomique, 1835, p. 38. 




Subastragaloid dislocation out' 
ward. (Malgaigne.) 



SUBASTRAGALOID DISLOCATIONS. 519 

somewhat in front of the part of the foot to which it normally corresponds. 
Above the outer surface of the calcaneum and cuboid is a notable depres- 
sion in the place of the usual prominences formed by the external malle- 
olus and the head of the astragalus. The internal malleolus is very 
prominent and nearer to the level of the sole, and below and in front of 
it is the projecting head of the astragalus. On the dorsum of the foot 
the scaphoid is recognizable with a depression behind it. 

C. Dislocation backward. 

In this the calcaneum and scaphoid are displaced directly backward, 
the scaphoid descending to a lower level so as to lie under the head or 
neck of the astragalus. Deviation of the foot to either side would create 
forms intermediate between this and the two preceding ones. A number 
of reported cases, which were claimed to be subluxations of this kind, 
the relations between the scaphoid and astragalus being changed, while 
those between the calcaneum and astragalus remained unchanged, were 
rejected by Broca as errors of diagnosis, but are accepted by Malgaigne 
as probably correct. In some of them reduction was easy ; in others it 
failed, but the persistence of the displacement did not permanently impair 
the functions of the limb. 

Of the complete form there are only two recorded examples : the first 
is the much quoted case of Prof. Carmichael, reported by Macdonald. 1 
Carmichael, in his effort to avoid a fall when his horse stumbled and 
came upon his knees, leaned back in the saddle and thrust his feet for- 
ward ; his weight was received upon the inner side of the ball of the right 
foot, and the dislocation was thereby produced, the deformity being so 
great that it was recognizable through his boot. The toes were abducted 
about 30°, the foot slightly everted: the concavity of the tendo-Achillis 
was manifestly increased, and the heel lengthened ; the astragalus could 
not be felt behind the tibia. Below and in front of the inner malleolus 
was a hard prominence, over which the skin was tense, formed by the 
inner surface of the astragalus. The most striking deformity was a 
prominence on the dorsum of the foot ; " immediately in front of the tibia 
it presented a flat surface broad enough to receive the finger, from which 
there was an abrupt descent upon the anterior part of the tarsus. Over 
the projection caused by the head of the astragalus throAvn on the upper 
surface of the scaphoid and cuneiform bones, the integuments were so 
tense that it was very evident a small additional force would have driven 
it through the skin." The distance from the internal malleolus to the 
end of the great toe was one inch less than on the other foot. No frac- 
ture could be found. Flexion and extension were very painful. The 
dislocation was reduced by traction with the pulleys, and direct pressure 
.on the heel and leg. 

The second case was observed by Thierry, and communicated to Mal- 
gaigne by Broca ; the dislocation was caused by a fall upon the toes ; 
the head of the astragalus was prominent under the skin, the front of the 
foot appeared shortened, the heel lengthened ; the foot was extended, and 
not deviated to either side. Good recovery. 

1 Macdonald: Dublin Quart. Journ. Med. Sci., 1838, vol. 14, p. 235. 



520 DISLOCATIONS AT OR NEAR THE ANKLE, 



D. Dislocations forward. 

Of this only two examples have been reported, one by Parise, quoted 
by Malgaigne, the other by Broca. 1 Parise's patient was injured by 
being crushed under a heavy weight, the thigh being flexed on the trunk, 
the leg on the thigh, and the foot on the leg (dorsal flexion). Nine 
months afterward the condition was as follows: the foot was at a right 
angle with the leg, a little adducted, and very slightly everted ; it was 
displaced forward, so that it appeared lengthened in front, and the ex- 
ternal malleolus almost touched the tendo-Achillis. The extensor tendons 
on the instep were tense, and no prominence could be felt beneath them, 
but on the outer side a bony prominence could be felt, which was thought 
to be the head of the astragalus, and immediately in front was a depres- 
sion which admitted the finger. The hollow between the astragalus and 
calcaneum seemed to be filled. Behind, the prominence of the heel was 
completely lost, the leg flattened, and its surface interrupted at the level 
of and a little below the malleoli by a bony prominence which raised the 
tendo Achillis and overlapped the heel nearly half an inch; above it was 
another, less prominent, formed by the posterior articular edge of the 
tibia. There was no trace of fracture, no separation of the malleoli. 
There was slight motion in the tibio-tarsal joint ; motion in the joints of 
the tarsus was entirely lost. The patient could hardly walk without 
crutches. 

In Broca's case the displacement was much less marked, and the only 
symptoms were an increase of one centimetre in the distance from the 
internal malleolus to the great toe, and a corresponding shortening of the 
heel, and the absence of abnormal prominence of the astragalus in front 
of the tibia. By traction and pressure under chloroform the inequality 
in the measurements was overcome and the patient, at the time of the 
report, was in a fair way .to recover. So far as can be judged from the 
report, Broca did not consider the diagnosis entirely clear, and the symp- 
toms as given are identical with those of Sarazin's case of incomplete 
tibio-tarsal dislocation forward. The differential diagnosis between these 
two injuries would have to be made on the existence of a gap between 
the astragalus and scaphoid in the subastragaloid dislocation, and the 
absence of such a gap and possibly the abnormal prominence of the upper 
articular surface of the astragalus in front of the tibia in the incomplete 
tibio-tarsal dislocation forward. The recognition of either symptom 
might be made difficult or impossible by swelling. 

Diagnosis of subastragaloid dislocations. — If the date of the injury is 
so recent that swelling has not yet supervened, or so remote that it has 
disappeared, the diagnosis may usually be made with considerable ease 
and certainty, but if swelling is present it may be very difficult. The 
important functional features are the preservation of the normal move- 
ments in the tibio-tarsal joint, and the loss or the exaggeration in one or 
the other direction of the lateral and rotatory movements of the foot 
which take place in the subastragaloid and medio-tarsal joints. As no 
lateral motion takes place in the tibio-tarsal joint, except in the position 

1 Broca: Report by Petit of a clinical lecture, Gaz. hebdom., 1874, p. 316. 



SUBASTRAGALOID DISLOCATIONS. 521 

of full plantar flexion, the exaggeration of the normal movement to either 
side must be due, when the ankle is sound, to injury of the last two 
named joints. The physical signs are the preservation of the relations 
between the astragalus and the bones of the leg, as shown by the normal 
relations of the malleoli to the head of the astragalus and by the absence 
of abnormal projection of the body of the astragalus in front or behind 
the tibia, the changes in length of the front part of the foot and heel, and 
the change in the relations of the calcaneum and scaphoid with the 
astragalus and the malleoli. 

Treatment of subastragaloid dislocations. — -The statistics collected by 
Broca and Poinsot give 23 simple cases in which reduction was attempted ; 
to these may be added Pick's 1 case. Of these 24 reduction was success- 
fully made in 14 and the ultimate result was good ; in 2 the reduction 
was incomplete, and 1 of these died of septicemia. The 8 failures (ex- 
cluding the 2 incomplete reductions) gave 4 secondary amputations with 
3 deaths, 3 secondary removals of the astragalus with 1 death, and 1 
good functional result notwithstanding the persistence of the deformity. 

In 7 additional cases in which the reduction was not attempted, 4 of 
the patients (Du Bourg, Dubreuil, See, quoted by Poinsot, and Quenu) 
had apparently good use of the limb, although in 1 of them sloughing 
and a violent arthritis followed the accident ; in 1, Brown, 2 reduction 
was made after six months ; in 2 (Sinnigen, quoted by Poinsot, Haifa 3 ) 
the disability was such that the patient sought relief; Sinnigen removed 
the astragalus and external malleolus, and at the time of the report death 
by septicaemia was expected; Raffa chiselled away the head and the neck 
of the astragalus and was then able to straighten the foot ; recovery 
without suppuration ; good result. 

In 2 cases (Verneuil, 4 Ore quoted by Poinsot), primary excision of the 
astragalus was done, in each with a good result. In Verneuil's there 
was fracture of the astragalus and rupture of the peroneal artery ; in 
Ore's an attempt to reduce had failed and gangrene of the tense skin was 
imminent. 

Of compound dislocations 17 cases were collected by Broca and 6 
additional by Poinsot in 1884, and to these 1 reported by Jackson 5 is to be 
added; of these reduction was made in 10, with 2 deaths, with persistent 
suppuration apparently maintained by necrosis in 2, and with secondary 
removal of the astragalus in 1. In 14 reduction was not made ; in 3 of 
these primary amputation was done, in 10 removal of the astragalus, with 
2 deaths, and in 1 the head of the astragalus became necrosed and was 
spontaneously cast out, the patient recovering. The results of primary 
removal of the astragalus, according to these statistics, are rather better 
than those of reduction, but, as has been said before, the value of these 
statistics as a basis for the choice of a method of treatment has been 
greatly diminished by the improvement in the methods of treatment of 
open wounds that has taken place in the last few years, and there is good 

i Pick: Lancet, 1880, i. p. 170. 

2 Brown: Lancet, 187B, i. p. 314. 

3 Kaffa : Centralblatt fur Chir., 1885, p. 211. 

4 Yerneuil : Bull, de la Soc. Anatomique, 1872, p. 493. 

5 Jackson: Lancet, 1881, ii. p. 590. 



522 DISLOCATIONS AT OR NEAR THE ANKLE. 

reason to hope that suppuration and its attendant dangers will be less 
frequent in future. 

Reduction, which has sometimes been made by traction with the hands 
alone, more frequently has needed the aid of the pulleys, even when 
anaesthesia has been employed. The knee should be flexed to relax the 
muscles of the calf, and the traction in the lateral cases should be down- 
ward and usually also forward, and coaptative pressure should be made 
upon the foot and leg. The cause of the irreducibility in some cases 
is not entirely clear ; it has been attributed to the engagement of the 
posterior lip of the astragalus in the groove on the upper surface of the 
calcaneum, and in the outward cases to the constriction of the astragalus 
under the tendon of the tibialis anticus. 

3. Total Dislocations of the Astragalus. 
(" Double dislocations of the astragalus.") 

This dislocation is a combination of the two preceding ones, the tibio- 
tarsal and the subastragaloid, the astragalus being simultaneously displaced 
from its normal relations with the bones of the leg, the calcaneum, and the 
scaphoid. It is much more frequent than either of the other two and is 
often compound. The astragalus may be displaced forward, backward, or 
to either side, or to any intermediate position, and may at the same time 
be rotated about any of its axes, or it may be rotated while remaining in 
the tibio-fibular mortise, The varieties of dislocation are, consequently, 
very numerous, but they may be grouped as dislocations forward, back- 
ward, outward and forward, and inward and forward, these terms 
indicating the direction in which the astragalus is displaced, and disloca- 
tions by rotation, including in the latter only those in which the bone 
remains more or less completely within the mortise. 

The causes are varied, the most common being falls from a height 
upon the feet and violent twisting of the foot, as when it has been caught 
between the spokes of a wheel. It is seldom possible to determine the 
exact mode of production in any given case, and experiment upon the 
cadaver has not done much to elucidate the subject; but it seems prob- 
able that dorsal or plantar flexion and abduction or adduction are requisite 
to rupture the ligaments that bind the astragalus to the other bones, and 
that then it is forced from its place by pressure exerted through the 
bones of the leg. 

A. Dislocation forward. 

In this form, which is very rare, the astragalus is displaced directly 
forward. To the briefly described and somewhat doubtful cases collected 
by Malgaigne, Delorme 1 added only two, in one of which (Morel-Lavallee) 
the astragalus had been rotated 180° about its vertical axis and both 
malleoli were broken : the foot was very movable on the astragalus, and 
the astragalus on the tibia. The sides of the bone could be distinctly 
felt, and its posterior surface, which looked directly forward. Reduction 
was easily made. In the other case, Barral, the dislocation was com- 

1 Delorme: Diet, de Med. et Chir. pratiques, 1879, vol. 27, p. 640. 



TOTAL DISLOCATIONS OF ASTRAGALUS. 523 

pound, the head of the astragalus projecting through the wound and 
resting on the dorsal surface of the scaphoid. Both it and the foot were 
freely movable. The extensor tendons and that of the tibialis anticus 
w r ere ruptured, the malleoli and calcaneum were broken. 

B. Dislocation ontivard and forward. 

In this, the most common form, the head of the astragalus rests on the 
outer cuneiform and the cuboid bones or even on the fifth metatarsal, its 
posterior part lying just within the mortise, and is freely movable; the 
foot is adducted and inverted and usually displaced bodily inward, so that 
the external malleolus is prominent and the internal hidden, and some- 
times the adduction of the front of the foot is very marked and combined 
with abduction of the heel. If the dislocation is compound the astragalus 
presents in the wound, which commonly extends backward to or beyond 
the external malleolus. The lower end of the fibula may be torn away 
from the tibia, and either or both malleoli broken. With the displace- 
ment may be combined various kinds and degrees of rotation of the 
astragalus, and sometimes the astragalus is broken. 

An exceptional form was observed by Kuster ;* a man in falling had 
his foot so twisted inward that its inner side was almost in contact with 
the leg; the astragalus projected outward below the external malleolus 
without change in the direction of its axis and with fracture of its neck, 
and as the skin covering it was dangerously stretched Kuster excised the 
posterior part of the bone, leaving the head, which had preserved its rela- 
tions with the scaphoid. Antiseptic dressing ; rapid recovery ; good 
functional result. 

C. Dislocation inward and forward,. 

In this, the second in order of frequency, the foot is everted and 
abducted, but sometimes is bodily displaced to the outer side without 
deviation. The astragalus projects in front of or below the internal 
malleolus, and its head appears always to be depressed, sometimes so far 
that the bone must have undergone rotation of 90° about its transverse 
axis. In a case reported by Hunt 2 it was so far rotated about its vertical 
axis that the head was directed toward the middle of the other foot. If 
the injury is compound the wound lies on the inner side and extends 
backward below the malleolus. It may be accompanied by fracture of 
the malleolus. 

D. Dislocation backward. 

In this form, which also is rare, the astragalus may be displaced back- 
ward or backward and to either side, and in some of the reported cases 
the bone has been broken at the neck and only the posterior fragment 
has been displaced. Malgaigne (loc. cit., p. 1058) collected 8 cases, in- 
cluding one reported by Denonvilliers, which he places (loc. cit., p. 1060) 
among "dislocations by rotation in place," but which, I think, belongs 

1 Kuster : Berlin, klin. Wochenschrift, 1877, p. 16. 

2 Hunt: Phila. Med. Times, 1872, vol. 3, p. 50. 



524 DISLOCATIONS AT OR NEAR THE ANKLE. 

here ; the cases are Phillips, 2, Lizars, Liston, Turner, Nelaton, Denon- 
villiers, and one anonymously reported in the Lancet, 1838-39, vol. 2, 
p. 559. To these Delorme adds 5, Blatin, Lejeune, MacCormac, 
Pichorel, and Oheever ; he also quotes Foucher as having reported two 
cases, but, I think, erroneously, one of them being Denonvilliers's case, 
the other Thierry's, a dislocation by rotation. Another case was reported 
by Munro, 1 and one by myself, 2 and another, Legros Clark, is reported 
in MacCormac's paper, making 16 in all. In the 7 printed in italics the 
bone was broken at the neck, and only the posterior fragment was dis- 
located. 3 

Of the 9 not complicated by fracture of the astragalus, the dislocation 
was backward in 6, backward and outward in 1, Turner, and backward 
and inward in 2, Lancet, Munro. Reduction was made in 3 (Lancet, 
Blatin, Munro), and failed in 4, the functional result being good in 3 of 
the latter ; Turner, and apparently Nelaton, removed the astragalus. 

Of the 7 complicated by fracture, the displacement in Lejeune's is 
described as backward, in the others as backward and inward; the dif- 
ference is slight, for in the latter the most prominent part of the astragalus 
projects but little beyond the level of the side of the internal malleolus. 
The tendons of the flexor longus digitorum and tibialis posticus are dis- 
placed upon the inner side of the malleolus, and that of the flexor longus 
pollicis sometimes lies to the outer side of the astragalus and sometimes 
is pushed directly backward by it. The fragment is also rotated, so that 
its trochlear surface looks inward, and its fractured surface is directed 
forward and downward. The line of fracture runs from the anterior 
border of the trochlea into the groove occupied by the interosseous liga- 
ment. In 3, Lejeune, MacCormac, Denonvilliers, the injury was com- 
pound ; in Cheever's the skin over the astragalus sloughed, but the ulcer 
soon healed without having exposed the bone. 

Reduction was made in none, although Pichorel divided the tendo- 
Achillis, and Cheever successively divided the tendo-Achillis, the tibialis 
anticus and posticus, the flexor longus digitorum, and the flexor longus 
pollicis at the toe. In three, MacCormac, Clark, Cheever, the patients 
recovered with good use of the limb ; in 1, Pichorel, suppuration followed 
and the limb was amputated ; in 2, Denonvilliers, Stimson, the posterior 
fragment was removed and both patients died, mine of pneumonia on the 
ninth day. The result in Lejeune's is not stated. (Compare also Krister's 
case above quoted.) 

The foot may appear somewhat shortened in front, and is not deviated ; 
the astragalus can be felt behind the ankle, either pressing the tendo- 
Achillis backward or lying on one side of it. If the entire bone is 
displaced the absence of the head from its normal position is shown by 
the depressibility of the soft parts behind the scaphoid. Marked, incor- 
rigible flexion of the terminal phalanx of the great toe is noted in three of 

1 Munro: Lancet, 1859, ii. p. 364. 

2 Stimson : N. Y. Med. Journal, May 28, 1887, p. 594. 

3 The following are two of the references : MacCormac (and Clark's case) : Trans. 
Path. Soc. London, 1875, vol. 26, p. 174, with plate of specimen obtained two years 
later. Cheever: Boston Med. and Surg. Journ., 1875, vol. 93, p. 237. 



TOTAL DISLOCATIONS OF ASTRAGALUS. 525 

the cases. In mine the tendons of the peroneus longus and brevis were 
displaced upon the outer side of the external malleolus. 

In the three cases in which reduction was made the means employed 
were traction followed by extension of the foot, traction, direct pressure, 
and inversion of the foot, and traction and direct pressure ; in Munro's 
case several months elapsed before the patient regained good use of the 
limb. 

E. Dislocation by rotation. 

In this class are not included those numerous cases in which the bone 
has undergone rotation in connection with displacement from the tibia 
and fibula, but only those in which it still lies mainly within the mortise. 

Two distinct varieties of this class may be made ; those in which the 
bone has been rotated upon its vertical or transverse axis, and also, 
perhaps, upon the antero-posterior axis, but still remains in great part 
within the mortise ; and those in which the bone still lies almost exactly 
in its normal position between the malleoli and has undergone only rota- 
tion about its antero-posterior axis. 

The division between the first variety and that of dislocations forward 
and inward is rather arbitrary and is perhaps not always to be made clini- 
cally, and the three cases collected by Malgaigne differ notably from one 
another. Barwell, 1 in a valuable paper containing a well observed and 
well reported case of his own and abstracts of all the other alleged cases 
except Chevallez's, proposes to term the injury dislocation of the foot 
with version, or with torsion, of the astragalus, applying the term version 
to the cases of rotation about the vertical axis, and torsion to those of 
rotation about the antero-posterior axis. I see no sufficient reason for 
using the term dislocation of the foot, which has already been employed 
for another form of injury ; and version and torsion do not in themselves 
indicate the sense in which they are used, but must be accompanied by a 
definition. 

Malgaigne gives four cases of rotation about the vertical axis, Barwell's 
" version," but I have placed one of them, Denonvilliers, among the 
dislocations backward To the remaining three Barwell adds two reported 
by Verebely ; 2 in three of them the head of the astragalus lay below the 
internal malleolus, in one just behind it, and in one just in front of the 
external malleolus. As they cannot well be grouped I give a summary 
of each. 

Laumonier. The head of the astragalus protruded under the inner 
malleolus between the tendons of the tibialis posticus and flexor longus 
digitorum, the trochlea lying transversely in the mortise and forcing 
apart the tibia and fibula. 

Foucher. 3 The specimen was taken from a subject found in the dis- 
secting-room. The astragalus had been rotated 90° about its vertical 
axis, the trochlea being still upright in the mortise, and the head below 
the internal malleolus. The tendon of the tibialis posticus and the 
posterior tibial artery lay in front of the internal malleolus. The posterior 

1 Barwell : Med. Chirur. Trans., 1883, vol. 66, p. 39. 

2 Yerebely : Wiener med. Wochenschrift, 1869, vol. 19, pp. 279 and 296. 

3 Foucher: Bull, de la Societe Anatomique, 1854, vol. 29, p. 388. 



526 DISLOCATIONS AT OR NEAR THE ANKLE. 

half of the astragalus lay on the calcaneum, the latter bone lying under 
the external malleolus and displaced forward and outward, and its axis 
directed forward and inward. The cuboid was partly dislocated down- 
ward from the calcaneum. There was no cicatrix ; the foot was flattened r 
the heel shortened. 

Thierry. The head of the astragalus projected midway between the 
internal malleolus and the tendo-Achillis, the outer border of the foot 
was much raised, and it was then seen that the bone was also so turned 
that its upper surface looked forward and inward, the tibia resting on the 
internal lateral face of the body of the bone, and the internal border of 
the trochlea exactly occupied the angle between the internal malleolus 
and the under surface of the tibia. Amputation ; recovery. 

Verebely : Male, twenty -nine. Fibula fractured above the malleolus. 
Under the internal malleolus the skin was very tense ; about an inch 
lower there was a hard bony prominence about half an inch in 
diameter. Reduction failed. At the end of the third week an abscess 
was opened, and it was seen that the prominence under the malleolus was 
the head of the astragalus. After four months' treatment the man could 
with difficulty put the foot to the ground. 

Verebely, second case. Male, forty-five. The foot was at right angles 
with the leg, the sole looking somewhat inward and upward. " Under 
the easily distinguishable outer malleolus and in front of it a long pro- 
jection half an inch in diameter may be plainly felt ; this can be moved 
without much pain backward and forward independently of the other 
bones. Behind the scaphoid is a considerable hollow." Reduction failed. 

Of the second variety, rotation about the antero-posterior axis, 
Malgaigne gives seven cases, most of which Barwell rejects because of 
the incompleteness of the description or because the astragalus was more 
or less displaced from the mortise. Rejecting Boyer's, Smith's, Liston's, 
and two of Dupuytren's, there still remain Malgaigne's own and one of 
Dupuytren's : to these are to be added Barwell's and Chevallez's. 1 In 
all four cases the condition was shown by direct examination : Malgaigne 
describes a specimen from an old case, Chevallez's patient was killed by 
the fall that caused the dislocation, and Dupuytren and Barwell excised 
the astragalus. In Malgaigne's, Chevallez's, and Barwell's the rotation 
was outward, that is, the upper surface of the trochlea had become 
external and rested against the inner face of the external malleolus, 
although in Malgaigne's the rotation was somewhat less than 90° ; in 
Dupuytren's the bone was turned completely upside down, rotation of 
180°. 

Of Malgaigne's specimen, which is represented in his Atlas, plate xxx., 
Fig. 5, it is said that the head of the astragalus rested on the scaphoid 
and cuboid : its trochlea, turned outward, corresponded almost entirely 
to the inner facet of the fibula, and its inner side lay under the tibia. 
The rotation, however, was not a complete quarter of a circle, for a por- 
tion of the outer side of the body of the astragalus could still be seen 
partly in contact with the point of the external malleolus and looking down- 
ward and outward. There was bony ankylosis between the astragalus 

1 Chevallez: Bull, de la Soc. Anatomique, 1870, vol. 45, p. 406. 






TOTAL DISLOCATIONS OF ASTRAGALUS. 527 

and calcaneum, and it was evident that the man had walked only on the 
outer border of his foot. 

In Chevallez's specimen there was subluxation of the head of the 
astragalus on the scaphoid, the upper surface of the trochlea was turned 
outward, the calcaneum was broken transversely and its posterior fragment 
driven up behind the astragalus ; the lateral ligaments of the ankle were 
detached, and the anterior border of the lower end of the tibia was broken. 

Dupuytren's patient was a man fifty years old, who had jumped from 
a ladder, alighting on his heel. There was a large, hard, irregular, and 
irreducible prominence in front of the tibia and extending to the instep. 
An incision was made parallel to the axis of the foot, and the head and 
neck of the astragalus were immediately brought into view. Efforts to 
remove the bone failed, for the posterior part was grasped and held fast 
between the tibia and calcaneum. On seeking for the cause of this fixa- 
tion it was found that the astragalus was turned around in such a way 
that its upper surface was directed downward, its lower upward, and that 
the hook -like process at its inferior and posterior part was fixed beneath 
the tibia so as completely to frustate our efforts to extract it. The patient 
did well. 

Barwell's patient, a man twenty-eight years old, was injured by the 
overturning of his wagon. "When seen an hour and a half after the acci- 
dent the foot was greatly inverted, its front somewhat turned in, the heel 
raised. The inner malleolus was much hidden ; beneath it the skin was 
thrown into two ridges by three deep folds drawn in segments of concen- 
tric circles from a centre a little above the malleolus. The outer malle- 
olus projected abnormally, the skin over it was rather tightly drawn. 
About an inch in front of it and a little below its level was a rounded 
projection, which also somewhat stretched the skin. An inch and a half 
up the leg and in front of the fibula was a small but deep wound. The 
foot was immovable and painful. Below and in front of the inner malle- 
olus deep pressure revealed absence of the usual bony substratum, the 
finger sank into a hollow bounded in front by the tuberosity of the 
scaphoid, which lay abnormally near the malleolus. The rounded pro- 
jection in front of the malleolus could readily be recognized as the head 
of the astragalus. A little way behind this was a ridge of bone, also 
evidently a part of the astragalus ; it led from the head backward and a 
little upward, disappearing under the upper part of the malleolus, at the 
angle between it and the anterior edge of the tibia. This ridge was 
markedly convex outward. The extensor tendons, pressed together, ran 
in a bundle a little distance inside the rounded projection. The wound 
communicated with the injury. No fracture could be detected. 

It was seen that the relations of the astragalus to the other bones were 
altered, although it was still within the mortise, but the exact nature of 
the injury was not recognized. Various attempts were made to reduce, 
and even the tendo-Achillis was divided, but in vain ; a moulded splint 
was applied, and the wound dressed with carbolic acid. 

Two days later a semilunar incision was made from the middle of the 
lower end of the tibia across the head of the astragalus to the tip of the 
outer malleolus, the flap turned up, and the bone fully exposed. It was 
a little turned on its vertical axis, the head having moved outward, and 



528 DISLOCATIONS AT OR NEAR THE ANKLE. 

90° on its antero-posterior axis, the trochlea being in contact with the 
cartilaginous surface of the external malleolus. The inner upper angle 
of the trochlea fitted closely into the reentrant angle formed by the 
external malleolus and the tibia. The bone was not at all displaced for- 
ward — that is, it- did not protrude abnormally from its socket. The 
interosseous ligament had been ruptured; the few remaining fibres were 
divided, and the bone removed. Examination of the cavity failed to 
show any fracture or detachment of cartilage. The patient made a good 
recovery, and was discharged nine and a half weeks after the operation. 

Treatment of total dislocations of the astragalus. 

The statistics, collected by Broca, Dubreuil, and Poinsot, show that of 
121 cases of dislocations not compound, 43 were successfully reduced, and 
it is worthy of note that Poinsot's list, composed of cases reported between 
1864 and 1883, shows 19 reductions in 31 cases, about 60 per cent., and 
as many of Broca' s cases were treated without the aid of anaesthesia it 
may reasonably be hoped that Poinsot's percentage is an indication of the 
success that will be obtained in future. Primary extirpation of the 
astragalus was done in 9 of the 121 cases, with 6 successes, 1 death, and 
2 deaths after secondary amputation. Consecutive extirpation was done 
in 41 cases, with 39 successes, and 2 deaths. Of 15 cases in which the 
dislocation remained unreduced, and in which the result is known (ex- 
cluding those of secondary extirpation) the functional result in 8 was good. 

Of 63 compound dislocations, collected by Broca, reduction was made 
in 9, and of these 9, 6 recovered, secondary removal of the astragalus was 
done in 2, and 1 died. Poinsot adds 2 cases in which reduction was 
made ; 1 was successful, in the other extirpation became necessary. 

In 58 compound cases primary removal of the astragalus was done, 
with 42 successes, 14 deaths, and 2 consecutive amputations followed by 
death. 

For reasons that have been already given, we have the right to expect 
better results in the future in compound cases, and may feel encouraged 
to make reduction whenever it is possible. Expectation in irreducible 
compound dislocations has almost always ended in removal of the astrag- 
alus, or amputation, or death, and the cases will probably be very few in 
which primary removal of the astragalus will not give the patient the most 
speedy recovery, the least risk, and the most useful limb. 

Of 56 simple irreducible dislocations contained in these statistics, sup- 
puration of the joint and sloughing of the skin followed in at least 41, 
and there is not much reason to suppose that the frequency of this result 
will be much, if at all, diminished in the future, for the exciting cause — 
bruising, pressure, and destruction of the blood-supply of the astragalus — 
will be repeated. It is important, therefore, to determine the proper 
course to be pursued under such circumstances. In 1884 Dr. McBurney, 
of New York, successfully reduced a dislocation forward and inward by 
exposing the head of the astragalus through an incision, and lifting the 
tendon of the tibialis anticus which tightly embraced the neck of the bone 
and had prevented reduction ; probably other equally good results will be 
obtained by the same means. Primary removal of the astragalus is 



MEDIO-TARSAL DISLOCATIONS. 529 

recommended by Barwell in all cases in which " certain and sufficient, 
but not too persevering, attempts at reduction" have failed, and the facts 
that four-fifths of the cases left to themselves have ended in suppuration 
and secondary removal of the astragalus, and that the functional result 
after removal is good, will be generally accepted as a justification of the 
advice, but it needs, I think, to be conditioned upon the failure of reduc- 
tion by arthrotomy. 

In a case of dislocation forward and outward Anger 1 reduced by making 
continuous traction by means of India-rubber for ten or fifteen minutes, 
and then pressing directly upon the bone. The rubber was attached to 
the foot by means of long strips of adhesive plaster passed in figure-of-8 
around the heel and dorsum to form a loop beneath the sole to which the 
rubber cords were fastened. 

In short, the plan to be pursued in simple cases is to attempt reduction 
by traction upon the foot with the hands or pulleys, under anaesthesia, 
and with the knee flexed, and by direct pressure so applied as first to 
correct such rotation of the bone as may exist, and then to force it back 
into place. This failing, expose the bone by incision, and seek to remove 
the obstacle to reduction and then to reduce ; this also failing, remove 
the astragalus. In cases in which the astragalus is not only dislocated 
but also broken, I think primary removal is the safest plan, even in cases 
of backward dislocation of the posterior fragment, although in three such 
treated without removal the patients recovered with useful limbs. 

In compound dislocations reduction is to be sought unless the astragalus 
is entirely detached or the lacerations are so extensive that suppuration 
is unavoidable ; otherwise, primary removal of the astragalus, or ampu- 
tation if clearly indicated. 

4. Medio-tarsal Dislocations. 

In this the dislocation takes place in the medio-tarsal joint, the scaphoid 
and cuboid being together displaced from the astragalus and calcaneum 
which preserve their relations to each other and to the bones of the leg. 
Broca, in the paper above quoted, pointed out that most dislocations pre- 
viously reported under this title were actually sub-astragaloid. Partial 
dislocation of the cuboid from the calcaneum appears to be frequently 
associated with sub-astragaloid dislocations, but the cases in which the 
medio-tarsal joint alone is involved are few. Cases, too briefly described 
to be positively accepted, were reported by J. L. Petit, Liston, and 
Cooper, but more recently three cases have been placed on record in two 
of which the diagnosis was confirmed at the autopsy. Thomas 2 reported 
a case in the service of Denonvilliers; the patient's foot had been crushed 
by the wheel of a cart. The plantar surface was convex, the dorsum so 
swollen that the bones could not be felt ; the foot was shortened, and its 
anterior portion could be moved laterally, but the movements were painful 
and accompanied by crepitation. The diagnosis of fracture of the head 

1 Th. Anger: Bull, de la Soc. de Chirurgie, 1875, vol. i. p. 219. 

2 Thomas: Mem. de la Soc. Med. d'Indre et Loire, 1887, quoted by Duplay and 
Delorrue. 

34 



530 DISLOCATIONS AT OR NEAR THE ANKLE. 

or neck of the astragalus and rapture of the calcaneocuboid ligaments 
was made. The patient died of erysipelas, and at the autopsy the tibio- 
tarsal and calcaneo-astragaloid joints were found intact ; the head of the 
astragalus and the cuboid surface of the calcaneum formed a very marked 
abnormal prominence above the second row of the tarsus ; the scaphoid 
was fractured antero-posteriorly, and its outer fragment projected on the 
plantar surface ; the cuboid was still in contact with the inferior half of 
the anterior end of the calcaneum ; the superior medio-tarsal ligaments 
were ruptured, and the inferior calcaneo-scaphoid partly detached ; the 
inferior calcaneo- cuboid was unbroken. 

Anger's 1 patient was injured by a fall from a height. There was slight 
flattening of the arch of the foot, without deviation, and with considerable 
ecchymotic and inflammatory swelling. He died of erysipelas. At the 
autopsy the head of the astragalus was found above and in front of the 
scaphoid, and the cuboid facet of the calcaneum upon the upper surface 
of the cuboid. The superior calcaneo-scaphoid and internal calcaneo- 
cuboid ligaments were ruptured and torn from their anterior insertions. 
It was difficult to reduce the dislocation even after dissection. The only 
fracture was of the anterior part of the scaphoid, the tubercle of which 
was almost entirely torn away. 

In the third case, Ward, 2 the dislocation was old. "The foot presented 
a remarkably twisted appearance, the anterior part being directed con- 
siderably inward, and the inner edge somewhat elevated." The dorsum 
was shortened one inch. The anterior ends of the calcaneum and astrag- 
alus projected distinctly on the dorsum. The external malleolus had 
been fractured. 

Congenital Dislocations of the Ankle-joint. 

Kraske 3 exhibited at the Ninth Congress of the German Surgical 
Society two patients, father and son, with congenital dislocation of both 
ankles, and also the two legs of another child of the same father w y hich had 
died in infancy and had been similarly affected. The abnormality was 
a subluxation outward accompanied by, and probably due to, defective 
development of the fibula. In all three cases the middle and upper part 
of the fibula was lacking, but in the specimen a small upper epiphysis 
existed. In the father the lower end of the fibula Avas only four centi- 
metres long and was obliquely placed, the apex directed outward. The 
articular surface of the tibia was also oblique, looking downward and 
outward ; the foot was flattened, markedly abducted, and moderately 
pronated. The legs, compared Avith the thighs, were abnormally short 
and slight. 

Resection of both ankles had been done upon the son to correct the 
faulty position of the foot: on the right side the internal malleolus and a 
comparatively large part of the astragalus had been removed; on the left, 
the entire lower end of the tibia and a small piece of the astragalus. 

Other forms of congenital subluxation belong to the subject of clubfoot. 

1 B. Answer : Traite icorm<rraphique, p. 834. 

2 AVaidr Trans. Puth. Soe. of London, 1849-50, p. 254. 

3 Kraske: Beibige zum Centralblatt fiir Chir., 1882, No. 29, p. 85. 






CHAPTEE XXXII. 

DISLOCATIONS OF THE TARSAL AND METATARSAL BONES 
AND OF THE TOES. 

In addition to the dislocations described in the preceding chapter, the 
bones of the tarsus may be dislocated separately and in various combina- 
tions. None of the different kinds has occurred with sufficient frequency 
to permit systematic grouping and description, and in most of them the 
exact nature of the injury cannot be said to have been positively estab- 
lished, for the difficulties of the diagnosis upon the living are usually 
very great and the surgeon is limited to the recognition of the more 
prominent features. I shall confine the account of them mainly to the 
enumeration of the different varieties that have been observed, with bib- 
liographical references for the convenience of those who may desire to 
examine the reports in detail. 

Calcaneum. — Malgaigne quotes a case in which the calcaneum was 
bodily displaced to the outer side, but apparently was not entirely separ- 
ated from the astragalus and scaphoid. Reduction was easy. Also a 
second (Canton, Lancet, 1847, i. p. 505) found upon the cadaver, in 
which the calcaneum was displaced to the outer side together with the 
external malleolus ; its anterior end lay between the cuboid and scaphoid, 
almost in contact with the third cuneiform ; and the astragalus was 
rotated inward about 45°. 

Scaphoid. — The scaphoid has been dislocated forward and outward in 
connection with the astragalus, the dislocation being compound (Burnett), 
forward and inward (Rizzoli, quoted by Poinsot), upward and backward 
in conjunction with the first and second cuneiforms and the first two 
metatarsals and with dislocation of the third metatarsal and fracture of 
the cuboid (Chassaignac, Bull, de la Soc. de Chir., 1861, vol. i. p. 307), 
upward and inward in conjunction with the first cuneiform (Lonsdale, 
Lancet, 1857, ii. p. 192) or with the middle cuneiform (Clarke, London 
Med. Times, 1851, vol. 3, p. 233), or outward, upward, or inward alone 
(Piedagnel, Walker, R. W. Smith, quoted by Malgaigne, Bryant, Surg., 
3d Am. ed., 1881, p. 813), or from the cuneiforms only, as seen by Gar- 
land [Lancet, 1857, ii. p. 270) in a case that was compound. In a case 
reported by Enos (N. Y. Journ. of Med., 1857, II. p. 98) the cuneiform 
bones and the cuboid w T ere displaced outward from the scaphoid and 
calcaneum. 

Cuboid. — The only case of dislocation of the cuboid of which I have 
knowledge, except in connection with other dislocations as above de- 
scribed, is one reported by Bell (N. Y. Journ. of Med., 1859, vol. 7, 
p. 329) in which it was displaced upward in connection with the fifth 
metatarsal by inversion and adduction of the foot. Reduction was made. 



532 DISLOCATIONS OF TAKSAL AND METATARSAL BONES. 

Cuneiform bones. — All three cuneiform bones and the second and third 
have been displaced together, and the first and second have been displaced 
separately. Isolated dislocations of the first are the most frequent, 
Lemoine 1 collected eleven such cases, to which may be added two observed 
by Bryant (loc. cit., p. 813); the displacement is usually upward and 
inward, in only one case downward and inward (Fitzgibbon, Dublin 
Journ. Med. Set., 1877, ii. p. 271); sometimes the bone is displaced 
from all the three with which it is normally in contact, sometimes the 
first metatarsal is displaced with it. The symptoms are flattening of the 
arch of the foot, prominence of the displaced bone, and a depression at 
its normal site. In some cases reduction has been easily made ; in others 
the attempt has failed. 

The second cuneiform has been separately dislocated upon the dorsum 
in three cases, Foulker (Lancet, 1856, ii. p. 283), Laugier, and 
Lagarde (quoted by Delorme, Diet, de Med. et Chir. prat., vol. 27, art. 
Pied), the displacement being slight in one and nearly complete in the 
others, and accompanied in one by other serious injuries of the foot, and 
followed in another (Foulker) by sloughing of the skin, grave symptoms, 
and ultimate recovery. In a case of multiple injuries of the foot 
reported by Lagrange (Bull, de la Soc. Anatomique, 1871, p. 180) the 
second cuneiform was displaced upward from all its connections except 
that with the scaphoid. 

The second and third cuneiforms were displaced together upon the 
dorsum in a case reported by Key (quoted by Malgaigne) ; the disloca- 
tion, which was incomplete, was caused by direct violence and accom- 
panied by extensive laceration of the skin. The patient died. 

All three cuneiforms have been reported displaced together upon the 
dorsum in several cases, but it does not appear in the histories whether 
or not they were separated only from the scaphoid or also from the cuboid 
and metatarsals; in one of them (Bertherand, Bull, de la Soc. de Chir., 
1856-57, vol. 7, p. 361) they were accompanied by the metatarsals and 
the dislocation could not be reduced. 

Dislocation of the Metatarsal Bones from the Tarsus 
and from one another. 

Malgaigne collected twenty-one cases of the various dislocations, and 
Hitzig 2 collected twenty-nine. 

The first metatarsal is much more frequently dislocated than the others, 
and the displacement appears always to have been upward except in one 
case (Demarquay, Bull, de la Soc. de Chir., 1870, vol. 10, p. 35) in 
which the base lay under that of the second metatarsal ; in this latter 
the first metatarso-phalangeal joint was also dislocated, compound, and 
Demarquay removed the bone. A frequent cause has been a fall while 
on a horse, the pressure of the stirrup against the inner and under surface 
of the bone apparently causing the injury. The symptoms frequently 
indicate the coexistence of a sprain of neighboring joints. Reduction 
has always been easy by traction and direct pressure. 

1 Lemoine : Revue de Chirurojie, 1883, vol. 3, p. 118. 

2 Hitzig : Berl. klin. Wochenschrift, 1865, p. 393. 



DISLOCATION OF METATARSAL BONES FROM TARSUS. 533 

Isolated dislocation of the second metatarsal upon the dorsum has been 
reported in one case, Brault and Belin, quoted by Hitzig ; that of the 
third downward and backward in one, Tufnell [Dublin Quart. Journ. 
Med. Sci., 1855, p. 302) ; that of the fourth upon the dorsum in three, 
Malgaigne, Surmay {Bull, de laSoc. de Chir.,1816, ii. p. 579), Gosselin 
(G-az. des Hopitaux, 1876, p. 755). 

The fourth and fifth metatarsals have been together dislocated upward 
and inward, Monteggia, and upward and backward, South ; both quoted 
by Malgaigne. The third and fourth, Hartmann, and the first and second, 
Marit, have been together displaced ; both quoted by Delorme. 1 The first, 
■second, and third were dislocated together upon the dorsum in two cases, 
Laugier, quoted by Malgaigne, and Wilms, quoted by Hitzig, and down- 
ward into the sole in a case reported by Tufnell (Dublin Quart. Journ. 
Med. Sei., 1854, vol. 17, p. 65); in the latter case the injury was caused 
by the fall of a horse and was irreducible, but the patient recovered 
good use of the limb ; the later history is recorded in the same journal, 
1855, vol. 20, p. 302. 

Dislocation of the second, third, and fourth together upon the dorsum 
was seen by Malgaigne once ; the same diagnosis was made by him in 
another case, but at the autopsy it was found that the fifth was also partly 
dislocated from the cuboid and that the first together with the internal 
cuneiform was displaced inward. 

Dislocation of the first four metatarsals has been reported in three 
cases, Malgaigne, Hitzig, Demarquay (G-az. des Hopitaux, 1865, p. 
534); in Malgaigne's the first three were displaced downward, the 
fourth upward ; in the other two the displacement was upward. Mal- 
gaigne was able to reduce the fourth, Demarquay the first, and Hitzig 
all ; notwithstanding the persistence of part of the dislocation the two 
patients had good use of the limb. 

All the metatarsal bones may be displaced together upward, inward, 
downward, or outward ; of the latter two forms only one example of 
each has been reported. Smyly (Dublin Quart. Journ. Med. Sci., 1854, 
vol. 17, p. 317) saw all five bones dislocated downward by the fall of a 
wagon which pressed the heel forward while the toes were fixed ; reduc- 
tion was made. The case of dislocation inward is Kirk's, quoted by 
Malgaigne, who distrusts the diagnosis. 

Of dislocation outward five cases have been reported, Laugier and 
Lacombe, quoted by Malgaigne, Tutschek, quoted by Hitzig, Mignot- 
Danton (Arch. gen. de Med., 1866, ii. p. 405), and Despres (Bull, de la 
Soc. Anatomique, 1878). The interlocking of the base of the second 
metatarsal between the first and third cuneiform bones must make a 
lateral dislocation impossible except as secondary to one upward or down- 
ward or unless accompanied by fracture ; in Laugier's and Dspres's the 
second metatarsal was broken at its upper end, and in Mignot-Danton's 
and Lacombe's the third was broken. In four cases reduction was made. 

Dislocation upward may be complete or incomplete, and sometimes the 
whole or a part of the first cuneiform remains attached to the first meta- 
tarsal and is displaced with it. Hitzig collected eleven cases. The most 

1 Delorme : Diet, de Med. et Chir. prat., vol. 27, art. Pied. 
34* 



534 DISLOCATIONS OF TARSAL AND METATARSAL BONES. 

frequent cause is direct violence, but in two cases it was muscular action, 
the efforts of the patients to avoid falling after having slipped while 
carrying heavy bundles. The autopsies and the compound cases have 
shown rupture of the dorsal and of some of the palmar ligaments, rupture 
and laceration of some of the interosseous ligaments and muscles, fracture 
of some of the metatarsal bones and occasionally of the cuboid and first 
cuneiform, and sometimes separation of the first or fifth metatarsal later- 
ally from the others. The metatarsus may remain in line with the rest 
of the foot or be deviated to either side, and the bases of its bones form a 
transverse ridge either corresponding exactly to the line of the joints or 
at a somewhat higher point upon the tarsus. Reduction was made more 
or less completely in some of the cases ; in others it failed, but the 
patients gradually recovered the use of the limb ; in one compound case, 
Mazot, primary amputation was done. 

Dislocations of the Toes. 

A. Metatarsophalangeal dislocations. 

1. Dislocations of the great toe. — Of this injury Malgaigne collected 
19 cases, to which Delorme added 12. The most common cause is a fall 
upon the toes ; among the less frequent are the act of kicking, receiving 
the weight of the body upon the toe alone in going upstairs, and violence 
received upon the metatarsus. The injury is frequently compound. The 
dislocation has been upward, backward, and to one side, the most frequent 
appearing to be those to the outer side and backward, and secondly those 
directly backward ; the former of these two is almost always compound 
with projection of the head of the metatarsal bone through the wound on 
the inner and lower aspect of the joint. Coexistent sprain or subluxation 
of the first tarso-metatarsal joint has been occasionally noted. 

Of 14 simple cases collated by Delorme reduction was easily made in 
8 and failed in 4 ; of the compound cases the head of the metatarsal bone 
was excised in 5, and the entire bone removed in 3 ; of 14 compound 
cases in which the attempt to reduce was made it was successful in 9. 
The means employed to reduce have been traction and direct pressure 
upon the base of the phalanx. Probably in the difficult cases the special 
procedures employed in the corresponding dislocations of the thumb Avould 
be advantageous. 

2. Dislocations of the other toes. — Dislocation of the four outer, the 
four inner, or of all five toes together has been reported in several cases, 
the direction of the displacement being upward and backward or directly 
outward ; in the latter the head of the metatarsal projected through a 
wound and had to be excised before reduction could be made. 

B. Dislocations of the phalanges. 

With one exception, the second phalanx of the third toe, in all the 
cases that have been reported the dislocation was of the terminal phalanx 
of the great toe. In one case reduction could not be made ; in another, 
which was compound, a portion of the bone was subsequently cast off. 



I N D E X. 



ACCIDENTS during reduction, 74 
Acetabulum, fracture of edge, 32 
floor, 413 
Acromion, fracture of, 31, 257 
After-treatment, 72 
Ambi, 61 

Anaesthesia, dangers of, 63 
Ankle, anatomy of, 508 

congenital dislocations of, 530 
dislocations at or near, 508 
Anterior dislocations of shoulder, 207 
Anterior oblique dislocation of hip, 421 
Arteries, injured in dislocation, 33 

in reduction, 79 
Astragalus (see Foot), 509 

dislocation by rotation, 525 
"double" or "total" dislocation 
of, 522 _ 
Atlas, dislocation of, 145 
Avulsion of forearm, 48, 78 
Axillary artery, injured in dislocation, 
" 34 
in reduction 80 



BIGELOW on reduction of hip, 425 
Bloodvessels injured during reduc- 
tion, 79 
in dislocation, 35 
at elbow, 35, 80 
at hip, 35, 449 
at shoulder, 80, 259 
Bone, overgrowth after dislocation, 45, 

344, 352 
Brachial artery, injured in dislocation, 
" 35, 288 
in reduction, 80 
Brachial plexus, torn in reduction, 89 



pALCANEUM, dislocation of, 531 
\.) Capsule, interposition of, 47 
Carpal bones, dislocation of, 367 
Carpometacarpal dislocations, 374 
Causes, determining, 24 

predisposing, 25 
Circumflex artery, injured in disloca- 
tion, 34 
in reduction, 81 
nerve, injured in dislocation, 36, 
258 



Clavicle, dislocations of, 173 
acromial end, 184 
subacromial, 191, 
subcoracoid, 193 
supra-acromial, 185 
both ends, 195 
statistics, 173 
sternal end, 174 
backward, 179 
forward, 175 
upward, 182 
Coccyx, dislocations of, 395 
Complications (see also Special disloca- 
tions), 30 
of bloodvessels, 33 
of bones, 31 
of nerves, 35 
of soft parts and skin, 39 
of viscera, 38 
Congenital dislocations (see also Special 
dislocations), 97 
etiology, 98 

pathology at elbow, 106 
at hip, 103 
at shoulder, 106 
statistics, 97 
symptoms, 106 
treatment, 108 
Coracoid process, fracture of, 257 
Coronoid process of ulna, fracture of, 

290 
Costal cartilages, dislocation of, 170 
Course, 56 
Crural nerve, pressed on in dislocation, 

437 
Cuboid, dislocation of, 531 
Cuneiform bones, dislocation of, 532 



424 



DEFINITIONS, 17 
Despres, method of, 
Distention, dislocation by, 112 
Divergent dislocation of radius and 

ulna, 315 
Dorsal dislocations of the hip, 409 
Double dislocations of the astragalus, 522 



PLBOW, anatomy of, 280 
ij dislocations of (see also Radius and 
Ulna), 280 



536 



INDEX, 



Elbow, backward dislocations, 285 
after-treatment, 298 
diagnosis, 292 
pathology, 287 
prognosis, 293 
symptoms, 291 
theories of production, 285 
treatment, 294 
classification, 283 
congenital and pathological, 

349 
divergent dislocation of radius 

and ulna, 315 
forward dislocations, 310 
fracture during reduction, 92 
frequency, 282 
injury of nerves in, 37 
injury of vessels in, 35, 80 
isolated, of radius and ulna, 317 
lateral dislocations, 298 
incomplete, 299 
inward, 301 
outward, 302 
complete outward, 306 
subepicondylar, 

308 
supraepicondylar, 
309 
old unreduced dislocations, 

treatment, 343 
relations to dislocation of 
shoulder and fracture of 
clavicle, 201 
Emphysema during reduction of 

shoulder, 76 
Ensiform process, dislocation of, 165 
Epitrochlea, fracture of, 288, 290, 303, 

313 
Etiology, 24 
Everted dorsal dislocation of hip, 418 



FAT embolism, 95 
Femoral artery, injured in disloca- 
tions, 35, 449 
Femoral vein, injured in dislocations, 

40, 430, 449 
Femur, fracture of head, 31, 413, 450 
of neck, 413, 438, 450 
of shaft, 452 
Fibula, dislocations of, 503 
lower end, 506 
spontaneous and pathological, 

506 
upper end, 503 

backward, 504 
forward, 504 
outward, 506 
upward, 505 
Fingers, dislocations of, 380, 389 
distal phalanges, 392 
metacarpo-phalangeal, 389 



Fingers, dislocations of middle phalan- 
ges, 391 
Foot, dislocations of, 509 

" by rotation outward," 514 
"upward," 515 
congenital dislocations, 530 
Foramen ovale, dislocation into, 428 

perforated, 429 
Forearm, avulsion of, 48, 78 
Fracture, as a complication, 31 
during reduction, 91 
of acetabulum, 453 
of epitrochlea, 288, 303, 313 
of femur, 3], 92,413,450 
of pelvis, 437, 453 
of tuberosities of humerus, 41 



n LENOID fossa, fracture of; 257 

HABITUAL dislocations, 27 
of hip, 455 
of shoulder. 262 
treatment, 73 
Hip, anatomy, 396 

dislocations of, 396-466 

accidents in reduction, 454 
after-treatment, 455 
backward dislocations, 408 

anterior oblique, 421 
dorsal, 409 

diagnosis, 417 
pathology, 410 
symptoms, 414 
everted dorsal, 418 
pathology, 420 
symptoms, 422 
treatment, 423 
classification, 404 
complications, 449 
compound, 39, 402 
congenital, 103 
directly upward, 441 
downward and inward, 428 
obturator, 428 
cause, 428 
pathology, 429 
symptoms, 431 
treatment, 433 
perineal, 435 
downward on tuberosity of 
ischium, 446 
fracture during reduction, 92, 450 
of acetabulum, 453 
of femur, 31, 413, 438, 450, 452 
of pelvis, 437 
habitual dislocations, 455 
ilio pectineal, 435 
injury of nerves in, 38, 91, 437, 450, 
461 
of vessels in, 35, 40, 430, 449 



INDEX. 



537 



Hip, dislocations of, infracotyloid, 446 
intra-pelvic, 410, 436 
labrum cartilagineum, detachment 

of, 453 
old dislocations, treatment of, 457 
arthrotomy, 458 
excision, 460 
osteotomy, 463 
subcutaneous section, 458 
paralysis of quadriceps extensor, 440 
paralytic dislocations, 464 
pathological dislocations, 463 
prseglenoid dislocations, 436 
prognosis, 455 
simultaneous of both hips, 18, 402, 

448, 453 
spontaneous dislocations, 463 
statistics, 401 
suspinous, 441 
suppuration after, 439 
supracotyloidea, 441 
suprapubic, 435 
suscotyloidienne, 441 
upward and forward (suprapubic), 
435 
pathology, 436 
symptoms, 438 
treatment, 410 
Humerus, fracture of anatomical neck, 
32, 254 
of shaft, 257 
of surgical neck, 254 
of tuberosities, 254 
Hyperextension in reduction at elbow, 
296 



TLEO-PECTINEAL dislocation of hip, 
I 435 

India-rubber, traction by, 69 
Infracotyloid dislocation of hip, 446 
Internal derangement of knee, 482 
Intracoracoid dislocation of shoulder, 

217 
Intrapelvic dislocation of hip, 436 
Ischium, dislocation on tuberosity, 446 



AW, dislocations of lower, 117 

backward, with fracture, 117 
congenital, 127 
forward, 119 
pathological, 126 



K 



NEE, anatomy, 466 
dislocations of, 466 
backward, 469 
by rotation, 480 
congenital, 486 
forward, 469 
injuries of nerves in, 472 



Knee, injuries of vessels in, 34, 470 
lateral, 476 

inward, 479 
outward, 476 
spontaneous and pathological. 

488 _ 
statistics, 469 
internal derangement, 482 
semilunar cartilages, 482 
Kocher, on reduction of hip, 426, 434 
of shoulder, 228 



LABRUM cartilagineum, detachment 
of, 453 
Luxatio erecta, 237 



MANIPULATION, reduction by, 65 
at hip, 424 
at shoulder, 227 
Median nerve, injury of, 36, 37 
Medio-carpal dislocations, 368 
Medio-tarsal dislocations, 529 
Metacarpophalangeal dislocations of 
fingers, 389 
of thumb, 380 
Metatarsal bones, dislocations of, 531 
Metatarsophalangeal dislocations, 534 
Muscles torn during reduction, 77 
Muscular action, a cause of dislocation,. 

77 
Musculo-spiral nerve, injury of, 291 
Myopathic dislocation of shoulder, 27£ 



YTERVES injured in dislocation, 35 
li injured in reduction, 89 

injured at elbow, 37, 291, 307, 312 

at hip, 38, 91, 437, 450, 461 

at knee, 472 

at shoulder, 258 



ABTURATOR dislocation, 428 
VJ Occiput, dislocation of, 143 
(Edema, persistent, 49, 94 
Olecranon, fracture of, 31, 290, 311 
Os magnum, dislocation of, 372, 374 



PARALYSIS after dislocation of hip, 
440 

of shoulder, 258 
Paralvtic dislocations, 112 

of hip, 464 

of shoulder, 278 
Patella, dislocations of, 490 

complete reversal, 498, 499 

congenital, 500 

edgewise or vertical, 497, 499 1 

inw r ard, 498 



533 



INDEX. 



Patella, dislocations of, outward, 493 

spontaneous or pathological, 
501 
Pathological dislocations, 111 
Pathology of old dislocations, 43 

of recent dislocations, 29 
Pelvis, dislocations of, 394 

fracture of, 437, 453 
Pendel-methode, at shoulder, 223 
Perinea] dislocations, 435 
Phalanges of hand, dislocations of, 380 
distal, 392 
middle, 391 
proximal, 380, 389 
of foot, dislocations of. 534 
Pisiform, dislocations of, 372 
Popliteal artery, injury of, 34, 470, 474 
Pouteau, on reduction by manipulation, 

67 
Prseglenoid dislocations of hip, 436 
Prognosis, 56 



RADIO-CARPAL dislocations, 356 
backward, 357 
forward, 361 
outward, 362 
congenital, 362 
pathological, 363 
Radius, fracture of, 290 

isolated dislocations of, 323 
backward, 324 
forward, 331 
outward, 328 
by elongation, 335 
with fracture of ulna, 340 
pathological and congenital, 
349 
Pecurrent dislocations, 27 
Reduction, 59 

accidents during, 74, 268, 454 
after long periods, 60, 457 
by manipulation, 65 
consecutive, 60 
obstacles to, 61 
spontaneous, 59 
Peid, on reduction of hip, 424 
Pepair, 40 

Rheumatism, dislocation in, 112 
Ribs, dislocations of, 167 



OCAPHOiD. dislocations of carpal, 
O 369 

tarsal, 531 
Schinzinger, on reduction of shoulder, 

231 
Sciatic nerve, pressure upon, 414, 461 
Semilunar bone, dislocation of, 370 

cartilages, dislocation of, 482 
Shoulder, anatomy, 197 

dislocations of, 197 to 279 



Shoulder, dislocations of, after-treat- 
ment, 261 
anterior, 207 

after-treatment, 232, 261 
intra-coracoid, 217 
subcoracoid, 207 
pathology, 211 
symptoms, 214 
treatment, 219 

by manipulation, 227 
Kocher, 22 S 
Schinzinger, 231 
direct reposition, 222 
heel in axilla, 226 
traction downward, 
222 
upward, 224 
with leverage, 225 
with pulleys, 227 
classification, 202 
complications, 253 

fracture of acromion, 257 
of coracoid, 257 

of glenoid fossa, 257 
of neck, 254 
of shaft, 257 
of tuberosity, 254 
injury of nerves, 258 
of vessels. 259 
compound dislocations, 259 
congenital dislocations, 271 
downward dislocations, 234 
luxatio erecta, 237 
subglenoid, 234 
symptoms, 237 
treatment, 237 
subtricipital, 238 
fracture, 32, 254 

during reduction, 92 
habitual dislocations, 262 
injury of nerves in, 35, 258 

of vessels in, 34, 80 
old dislocations, treatment, 266 
arthrotomy, 268 
excision, 269 
fracture, 270 
osteotomy, 271 
subcutaneous section, 
267 
paralytic dislocations, 278 
pathological, 276 
posterior dislocations, 240 
symptoms, 245 
treatment, 247 
prognosis, 261 

relation to other injuries, 201 
simultaneous of both shoulders, 

260 
statistics, 200 

upward (supracoracoid), 248 
Skin, torn during reduction, 75 
Smith, Nathan, on manipulation, 68, 424 



INDEX. 



53£ 



Spinal column (see Vertebra?), 128 
Spontaneous dislocations, 111 

reduction, 59 
Statistics, general, 20 
Sternum, dislocations of, 161 
Subacromial dislocation of clavicle, 191 

of shoulder, 240 
Subastragaloid dislocations, 516 

diagnosis, 520 

treatment, 521 
Subepicondylar dislocation, 307 
Subclavicular dislocation, 217 
Subcoracoid dislocation of clavicle, 193 

of shoulder, 207 
Subcotyloid dislocation of hip, 446 
Subglenoid dislocation, 234 
Subscapular artery torn, 81 
Subspinous dislocation of hip, 441 

of shoulder, 240 
Subtricipital dislocation, 239 
Suppuration, 40, 93, 439 
Supra-acromial dislocation of clavicle, 

165 
Supracoracoid dislocation of shoulder, 

240 
Supracotyloid dislocation of hip, 441 
Supraepicondylar dislocation, 307 
Suprapectineal dislocation, 410, 436 
Suprapubic dislocation, 435 
Sus-cotyloidienne dislocation, 441 
Symptoms, 50 
Syncope, 95 



TARSAL bones, dislocation of, 531 
Thumb, dislocations of, 380 , 
distal phalanx, 392 
proximal phalanx, 380 
Thyroid dislocation, 428 



Tibio-tarsal dislocation, 509 
Toes, dislocation of, 534 
Trapezium, dislocation of, 373 
Trapezoid, dislocation of, 373, 374 
Treatment, 59 
Typhoid fever, dislocation in, 112 



ULNA, fracture with dislocation of 
radius, 340 
isolated dislocation of, 319 
Ulnar nerve, injured, 36, 307, 312 
Unciform, dislocation of, 372 



YTERTEBR.E, dislocations of, 128 
V atlas, 145 

cervical vertebrae, 149 

classification, 131 

dorsal vertebrae, 157 

etiology, 137 

lumbar vertebrae, 159 

occiput, 143 

pathology, 131 

prognosis, 140 

statistics, 128 

symptoms, 137 

treatment, 141 
Viscera, injury to, 38 
Voluntarv dislocations, 27 



W 



RIST, dislocations of, 352, 356- 
of fibro-cartilage of, 337 
pathological, 363 



"-LIGAMENT, 398 
ossified, 431 



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text-books, giving not only the details necessary for the student, but also the application to 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
has been taken by the issue of the work with the arteries, veins and nerves distinguished 
by different colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details of the dissecting-room. Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume will be published also in black alone, and main- 
tained in this style at the price of former editions, notwithstanding the largely increased 
size of the work. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered 
by type and illustration in anatomical study. 



The most popular work on anatomy ever written. 
It is sufficient to say of it that this edition, thanks 
to its American editor, surpasses all other edi- 
tions —Jur. <f the Amer. Me . Ass'n, Dec 31, 1887. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy 
throughout the civilized world comes to hand in 
such beauty of execution and accuracy of text 
and illustration as more than to make good the 
large promise of the prospectus. It would be in- 
deed difficult to name a feature wherein the pres- 
ent American edition of Gray could be mended 
or bettered, and it needs no prophet to see that 



the royal work is destined for many years to come 
to hold the first place among anatomical text- 
books. The work is published with black and 
colored plates. It i^ a marvel of book-making. — 
American fracJition r and News, Jan. '21,1888. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language. — Cincinnati 
Medical News, Nov 1887. 

As the book now goes to the purchaser he is re- 
ceiving the best work on anatomy that is published 
in any language.— Virginia Med. Monthly, Dec. 1887. 



Also for sale separate — 
HOLDEJST, LTJTHEB, F. JR. C. 8. 9 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 

Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- 
delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. 

This little book is all that can be desired within 
its scope, and its contents will be found simply in- 
valuable to the young surgeon or physician, since 
they bring before him such data as he requires at 
every examination of a patient. It is written in 
language so clear and concise that one ought 
almost to learn it by heart. It teaches diagnosis by 
external examination, ocular and palpable, of the 
body, with such anatomical and physiological facts 
as directly bear on the subject. It is eminently 
the student's and young practitioner's book. — Phy- 
sician and Surgeon, Nov. 1881. 

The study of these Landmarks by both physi- 



cians and surgeons is much to be encouraged. It 
inevitably leads to a progressive education of both 
the eye and the touch, by which the recognition of 
disease or the localization of injuries is vastly as- 
sisted. One thoroughly familiar with the facts here 
taught is capable of a degree of accuracy and a 
confidence of certainty which is otherwise unat- 
tainable. We cordially recommend the Landmarks 
to the attention of every physician who has not 
yet provided himself with a copy of this useful, 
practical guide to the correct placing of all the 
anatomical parts and organs. — Canada Medical and 
Surgical Journal, Dec. 1881. 



Lea Brothers & Co.*s Publications — Anatomy, 



ALLIEN, HARRISON, M. L>., 

Professor oj Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section 1. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fascia. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, 
and General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00; very handsome half Kussia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 

It is to be considered a study of applied anatomy I care, and are simply superb. There is as much 
In its widest sense — a systematic presentation of j of practical application of anatomical points to 
such anatomical facts as can be applied to the | the every-day wants of the medical clinician as 

to those of the operating surgeon. In fact, few 



practice of medicine as well as of surgery. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con 



general practitioners will read the work without a 
feeling of surprised gratification that so many 
points, concerning which they may never have 



sidered a dry subject. The department of Histol- thought before are so well presented for their con 



ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 



iar with it. The illustrations are made with great Record, Nov. 25, 1882. 



sideration. It is a work which is destined to be 
the best of its kind in any language. — Medical 



CLARKE,W. B.,F.R.C.S. & LOCJKWOOD,C.B.,F.R.aS. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 4. 

Messrs.Clarke and Lockwood have written abook 
that can hardly be rivalled as a practical aid to the 
dissector. Their purpose, which is "how to de- 
scribe the best way to display the anatomical 
structure," has been fully attained. They excel in 
a lucidity of demonstration and graphic terseness 
of expression, which only a long training and 



intimate association with students could have 
given. With such a guide as this, accompanied 
by so attractive a commentary as Treves' Surgical 
Applied Anatomy (same series), no student could 
fail to be deeply and absorbingly interested in the 
study of anatomy. — New Orleans Medical and Sur- 
gical Journal, April, 1884. 



TREVES, FREDERICK, F. R. C. S., 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, 
page 4. 



Be has produced a work which will command a 
larger circle of readers than the class for which it 
was written. This union of a thorough, practical 
acquaintance with these fundamental branches, 



quickened by daily use as a teacher and practi- 
tioner, has enabled our author to prepare a work 
which it would be a most difficult task to excel. — 

The American Practitioner, Feb. 1884. 



CURNOW, JOHN, M. JD., F. R. C JP., 

Professor of Anatomy at King's College, Physician at King's College Hospital. 
Medical Applied Anatomy. In one pocket-size 12mo. volume. Shortly. See 
Students' Series of Manuals, page 4. 

BELLA31T, EDWARD, F. R. C. S., 

Senior Assistant- Surg eon to the Charing- Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Regions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

WILSON, ERASMUS, F. R. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Gobrecht, M. D., Professor of General and* Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLELAND, JOHN, M. L>., F. R. S., 

Professor of Anatomy and Physiology in Queen's College, Galway. 

A Directory for the Dissection of the Human Body. 

volume of 178 pages. Cloth, $1.25. 



In one 12mo. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
In one royal 12mo. volume of 310 pages, with 220 
woodcuts. Cloth, 81.75. 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and 
modified. In two octavo volumes of 1007 pages 
with 320 woodcuts. Cloth, $6.00. 



Lea Brothers & Co.'s Publications — Physics, Physiol., Anat, 7 
&BAJPEB, JOHN C., M. !>., LL. &., 

Professor of Chemistry in the University of the City of New York. 
Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 

FROM THE PREFACE. 

The fact that a knowledge of Physics is indispensable to a thorough understanding of 
Medicine has not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Kobertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel. A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of the City of New York. 

Broadly speaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
pursuit of this object whatever experience the author has gained during a long period of 
teaching this special branch of applied science. 

This elegant and useful work bears ample testi- ; explained, acoustics, optics, heat, electricity and 

magnetism, closing with a section on electro- 
biology. The applications of all these to physiology 
and medicine are kept constantly in view. The 
text is amply illustrated and the many difficult 
points of the subject are brought forward with re- 
markable clearness and ability. — Medical and Surg- 
ical Reporter, July 18, 1885. 

That this work will greatly facilitate the study 
of medical physics is apparent upon even a mere 
cursory examination. It is marked by that scien- 
tific accuracy which always characterizes Di. 
Draper's writings. Its peculiar value lies in the 
fact that it is written from the standpoint of the 
medical man. Hence much is omitted that ap- 
pears in a mere treatise on physical science, while 
much is inserted of peculiar value to the physi- 
cian. — Medical Record, August 22, 1885. 



mony to the learning and good judgment of the 
author. He has fitted his work admirably to the 
exigencies of the situation by presenting the 
reader with brief, clear and simple statements of 
such propositions as he is by necessity required to 
master. The subject matter is well arranged, 
liberally illustrated and carefully indexed. That 
it will take rank at once among the text-books is 
certain, and it is to be hoped that it will find a 
place upon the shelf of the practical physician, 
where, as a book of reference, it will be found 
useful and agreeable. — Louisville Medical News, 
September 26, 1885. 

Certainly we have no text-book as full as the ex- 
cellent one he ha? prepared. It begins with a 
statement of the properties of matter and energy. 
After these the special departments of physics are 



BOBERTSON, J. McGBEGOR, M. A., M. B., 

Muirhead Demonstrator of Physiology, University of Glasgow. 

Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 4. 

The title of this work sufficiently explains the j ments. It will be found of great value to the 
nature of its contents. It is designed as a man- j practitioner. It is a carefully prepared book of 
ua! for the student of medicine, an auxiliary to j reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- j heartily recommend it.— Journal of the American 
larly useful as a guide to his laboratory experi- | Medical Association, Dec. 6, 1884. 

&ALTON, JOHN C, M. T>. 9 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York, 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 



Dr. Dalton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitute and admir- 
ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands.— New Orleans 
Medical and Surgical Journal, Aug. 1885. 

In the progress of physiological study no fact 
was of greater moment, none more completely 



revolutionized the theories of teachers, than the 
discovery of the circulation of the blood. This 
explains the extraordinary interest it has to all 
medical historians. The volume before us is one 
of three or four which have been written within a 
few years by American physicians. It is in several 
respects the most complete. The volume, though 
small in size, is one of the most creditable con- 
tributions from an American pen to medical history 
that has appeared. — Med. & Surg. Rep., Dec. 6, 1884. 



BELL, F. JEFFREY, M. A., 

Professor of Comparative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 
with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 4. 



The manual is preeminently a student's book — 
clear and simple in language and arrangement. 
It is well and abundantly illustrated, and is read- 
able and interesting. On the whole we consider 



it the best work in existence in the English 
language to place in the hands of the medical 
student. — Bristol Medico-Chirurgical Journal, Mar., 
1886. 



ELLIS, GEORGE VINER, 

Emeritus Professor of Anatomy in University College, London. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. 

ROBERTS, JOHN B., A. M., M. L>., 

Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. for Graduates in Medicine. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 



8 Lea Brothers & Co.'s Publications — Physiology, Clieinistry, 



CHAPMAN, HENKY C, M. D., 

Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of 
Philadelphia. 

A Treatise on Hainan Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, $5.50 ; leather, $6.50. Just ready. 

farther, and the latter will rind entertainment and 
instruction in an admirable book of reference. — 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical -ml Surgical Journal, Dec. 1887 

Mattel s which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 
nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 



North Carolina Medical Journal, Nov. 1887. 

The work certainly commends itself to both 
student and practitioner. What is most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
take place among the most valuable text-books. — 
Mtdical Age, Nov. 25, 1887. 

It is the production of an author delighted with 
his work, and able to inspire students with an en_ 
thusiasm akin to his own. — American Practitioner~ 
and News, Nov. 12, 1887. 



DALTON, JOHN a, M. JJ., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 

This edition of Dr. Dal ton's well-known work 
bears evidence of having been thoroughly and 
careiuily revised. From the first appearance of 
the book it has been a favorite, owing as well to 
the author's renown as an oral teacher as to the 
charm of simplicity with which, as a writer, he 
always succeeds in investing even intricate sub- 
jects It must be gratifying to him to observe the 
frequency with which his work,written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 



sands who have studied it in its various editions 
have never been in any doubt as to its sterling 
worth.— N. Y. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those Dranches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



FOSTER, MICHAEL, M. D., E. M. S., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, England. 
Text-Book of Physiology. Third American from the fourth English edition, 
with notes and additions by E. T. Keichert, M. D., Professor of Physiology in the Uni- 
versity of Pennsylvania. In one handsome royal 12mo. volume of 908 pages, with 271 
illustrations. Cloth, $3.25 ; leather, $3.75. 



Dr. Foster's work upon physiology is so well- 
known as a text-book in this country, thatitneeds 
but little to be said in regard to it. There is 
scarcely a medical college in the United States 
where it is not in the hands of the students. The 
author, more than any other writer with whom 
we are acquainted, seems to understand what 
portions of the science are essential for students 



to know and what may be passed over by them as 
not important. From the beginning to the end, 
physiology is taught in a systematic manner. To 
this third American edition numerous additions, 
corrections and alterations have been made, so 
that in its present form the usefulness of the book 
will be found to be much increased. — Cincinnati 
Medical News, July 1885. 



POWEM, HENMY, M. B., E. M. C. $., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students 1 Series of Manuals, p. 4. 

SIMON, W., Eh. !>., M. I)., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and 
Professor of Chemistry m the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
In one 8vo. vol. of 410 pp., with 16 woodcuts and 7 plates, mostly of actual deposits, 
with colors illustrating 56 of the most important chemical reactions. Cloth, $3.00 ; also 
without plates, cloth, $2.50. 

This book supplies a want long felt by students 
of medicine and pharmacy, and is a concise but 
thorough treatise on the subject. The long expe- 
rience of the author as a teacher in schools of 
medicine ana pharmacy Is conspicuous in the 
perfect adaptation of the work to the special needs 
* these branches. The colored 



ptation 
lent of 



plates, beautifully executed, illustrating precipi- 
tates of various reactions, form a novel and valu- 
able feature of the book, and cannot fail to be ap- 
preciated by both student and teacher as a help 
over the hard places of the science.— Maryland 
Medical Journal, Nov. 22, 1884. 
of the stuc" 

Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Remsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 

CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
ease. With explanations of scientific words. SmaU 
12mo. 178 pages. Cloth, 60 cents. 



LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 

CARPENTER'S HUMAN PHYSIOLOGY. Edited 
by Henry Power. In one octavo volume. 



GALLOWAY'S QUALITATIVE ANALYSIS. 



Lea Brothers & Co.'s Publications — Chemistry* 



FRANKLAJSD, E., D. C. L., F.R.S., &JAFF, F. K., F. I. C., 

Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Professor of Chemistry in the Normal School 
of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 
woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry, with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 
chemical knowledge is behind the times, would 
do well to devote some of their leisure time to the 
study of this work. The descriptions and demon- 
strations are made so plain that there is no diffi- 
culty in understanding them. — Cincinnati Medical 
News, -January, 13S6. 



This excellent treatise will not fail to take its 
place as one of the very best on the subject of 
which it treats. We have been much pleased 
with the comprehensive and lucid manner in 
which the difficulties of chemical notation and 
nomenclature have been cleared up by the writers. 
It shows on every page taat the problem of 
rendering the obscurities of this science easy 
of comprehension has long and successfully 
engaged the attention of the authors. — Medical 
and Surgical Reporter, October 31, 1885. 



FOWJSTFS, GEOBGE, Fh. J). 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical Inorganic Chemistry. New American edition. In one large 
royal 12mo. volume of 1061 pages, with 168 illustrations on wood and a colored plate. 
Cloth, $2.75 ; leather, $3.25. 

Fownes 1 Chemistry has been a standard text- | chemistry extant. — Cincinnati Medical News, Oo- 
book upon chemistry for many years. Its merits 
are verv fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has stealily 
maintained its position as a text book with medi- 
cal students. In this work are treated fully: Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 



tober, 1885. 

Of ail the works on chemistry intended for the 
use of medical students, Fownes' Chemistry is 
perhaps the most widely used. Its popularity is 
based upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts 5 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students. — New Orleans Medical 
and Surgical Journal, March, 1886. 



ATTFIELJD, JOttX, Flu I)., 

Professor of Practical Chemistry to the Pharmaceutical Society of Ghreat Britain, etc 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the tenth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of 728 pages, with 87 illustrations. Cloth, $2.50 ; leather, $3.00. 

It is a book on which too much praise cannot be j in sixteen years must have good qualities. It 
bestowed. As a text-book for medical schools it 
is unsurpassable in the present state of chemical 
science, and having been prepared with a special 
view towards medicine and pharmacy, it is alike 
indispensable to all persons engaged in those de- 
partments of science. It includes the whole 
chemistry of thelast Pharmacopoeia. — Pacific Medi- 
cal and Surgical Journal, Jan. 1884 



A text-book which passes through ten editions | nal, April, 1884. 



seems desirable to point out that feature of the 
book which, in all probability, has made it so 
popular. There can be little doubt that it is its 
thoroughly practical character, the expression 
being used in its best sense. The author under- 
stands what the student ought to learn, and is able 

re- 
our~ 



to put himself in the student's place and to appi 
ciate his state of mind. — American Chemical Jot 



BLOXAM, CHARLES L., 

Professor of Chemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. 

Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations ol 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 



Cloth, $2,00 ; leather, $3.00. 
the best manuals of general chemistry in the Eng- 
lish language.— Detroit Lancet, Feb. 1884. 

We know of no treatise on chemistry which 
contains so much practical information in the 
same number of pages. The book can be readily 
adapted not only to the needs of those who desire 
a tolerably complete course of chemistry, but also 
to the needs of those who desire only a general 
knowledge of the subject. We take pleasure in 
recommending this work both as a satisfactory 
text- book, and as a useful book of reference.— Bos- 
ton Medical and Surgical Journal, June 19, 1884. 



GREENE, WILLIAM K. 9 M. JD., 

Demonstrator ol Chemistry in the Medical Department of the University of Pennsylvania. 

A Manual of Medical Chemistry. For the use of Students. Based upon Bow* 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 
It is a concise manual of three hundred pages, I the recognition of compounds due to pathological 
giving an excellent summary of the best methods conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of thestu- 
for the estimation of their normal constituents and dent or practitioner.— Boston Jl. of'Chem. June,'80. 



10 



Lea Brothers & Co.'s Publications — Chemistry. 



REMSEN, IRA, M. D>, JPh. D., 

Professor uf Chemistry in the Johns Hopkins University, Baltimore. 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- 
some royal 12mo. volume of 316 pages. Cloth, $2.00. just ready. 

This work of Dr. Remsen is the very text-book I examination of college faculties as the text-book of 
needed, and the medical student who has it at j chemical instruction.—^. Louis Medical and Sur- 
his fingers' ends, so to speak, can, if he chooses, j gical Journal, January, 1888. 

make himself familiar with any branch of chem- ' It is a healthful sign when we see a demand for 
istry which he may desire to pursue. It would be a third edition of such a book as this. This edi- 
difficult indeed to find a more lucid, full, and at tion is larger than the last by about seventy-five 
the same time compact explication of the philos- pages, and much of it has been rewritten, thus 
ophy of chemistry, than the book before us, and j bringing it fully abreast of the latest investiga- 
te recommend it to the careful and impartial | tions.— i\ r . Y. Medical Journal, Dec. 31, 1887. 

CHARLES, T. CRANSTOUJST, M. D., F. C. S., M.S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queerts College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 



Dr. Charles is fully impressed with the import- 
ance and practical reach of his subject, and he 
has treated it in a competent and instructive man- 
ner. We cannot recommend a better book than 
the present. In fact, it fills a gap in medical text- 
books, and that is a thing which can rarely be said 



nowadays. Dr. Charles has devoted much space 
to the elucidation of urinary mysteries. He does 
this with much detail, and yet in a practical and 
intelligible manner. In fact, the author has filled 
his book with many practical hints.— Medical Rec- 
ord, December 20, 1884. 



HOFFMANN, F., A.M. 9 Fh.D., & BOWER F.B., Ph.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

tion of them singularly explicit." Moreover, it is 
exceptionally free from typographical errors. We 
have no hesitation in recommending it to those 



We congratulate the author on the appearance 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



who are engaged either in the manufacture or the 
testing of medicinal chemicals. — London Pharma- 
ceutical Journal and Transactions, 1883. 



CLOWES, FRANK, D. 8c., London, 

Senior Science- Master at the High School, Neivcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth, 

$2.50. 

It is the most readable book of the kind we have 
yet seen, and is without doubt a systematic, 
intelligible and fully equipped laboratory guide 
and text-book.— M edical Record, July 18, 1885. 



The style is clear, the language terse and vigor- 
ous. Beginning with a list of apparatus necessary 
for chemical work, he gradually unfolds the sub- 
ject from its simpler to its more complex divisions. 



RALFE, CHARLES JBL., M. D., F. R. C. F., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 
illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 4. 

This is one of the most instructive little works ! cine. Dr. Ralfe is thoroughly acquainted with the 
that we have met with in a long time. The author j latest contributions to his science, and it is quite 
is a physician and physiologist, as well as a chem- I refreshing to find the subject dealt with so clearly 
1st, consequently the book is unqualifiedly prac- and simply, yet in such evident harmony with the 
tical, telling the physician just what he ougnt to modern scientific methods and spirit. — Medical 
know, of the applications of chemistry in medi- | Record, February 2, 1884. 

CLASSEN, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00. 

It is probably the best manual of an elementary and then advancing to the analysis of minerals and 
nature extant, insomuch as its methods are the such products as are met with in applied chemis- 
best. It teaches by examples, commencing with try. It is an indispensable book for students m 
single determinations, followed by separations, chemistry.— Boston Journal of Chemistry, Oct. 1878. 



Lea Brothers & Co.'s Publications— Piiarm., Mat. Med., Tiierap. 11 



BRUNTOJSr, T. LAUDER, M.D., L>.$c, F.B.S., F.B.C.I*., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. 

A Text-book of Pharmacology, Therapeutics and Materia Medica ; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
In one handsome octavo volume of 1033 pages, with 188 illustrations. Cloth, $5.50 ; 

leather, $6.50. 

It is a scientific treatise worthy to be ranked with | compiled that a reference to any special point is 
the highest productions in physiology, either in at once obtainable. Dr. Brunton is never satisfied 
our own or any other language. Everything is with vague generalities, but gives clear and pre- 
practical, the dry, hard facts of physiology being I cise directions for prescribing the various drugs 



pressed into service and applied to the treatment 
of the commonest complaints. The information 
is so systematically arranged that it is available 
for immediate use. The index is so carefully 



d preparations. We congratulate students on 
being at last placed in possession of a scientific 
treatise of enormous practical importance.— The 
London Lancet, June 27, 1885. 



MAISCH, JOHWM., JPhar. L>., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New (3d) edition, thoroughly revised. In one handsome royal 12mo. 
volume of 523 pages, with 257 illustrations. Cloth, $3. Just Beady. 

Prof. Maisch is one of the most distinguished j of a third edition besides saying that it is what 
pharmacists of this country. He and Prof. Stille one would expect from its talented author. The 
are the authors of The National Dispensatory, arrangement of the subjects is systematic, accord- 
which is not excelled by any work of its kind ever ing to classes. The origin, habitat, description, 
published. The learning and experience of the constituents and properties of each drug are given 
author, therefore, is a guarantee that his manual in a clear and very succinct manner; and the 
is well adapted for its purpose, viz. : a text- and whole book is full of valuable information. The 
reference-book for students, pharmacists and phy- j work of the publishers is as creditable as that of 
sicians, containing the most recent and reliable the author, the paper, printing and binding being 
information in regard to drugs.— Cincinnati Medi- of the highest order of excellence, while the illus- 
cal News, Nov. 1887. trations are superb. — Medical and Surgical Beport- 

This work has already met with so much favor er, Nov. 19, 1887. 
that there is little to do in noting the a ppearance 

BABTHOLOW, BOBEBTS, A. M., M. D., LL. D., 

Professor of Materia Medica and General Therapeutics in the Jefferson Medical College of Phila- 
delphia. 

New Remedies of Indigenous Source: Their Physiological Actions and 
Therapeutical Uses. In one octavo volume of about 300 pages. Preparing. 

CAMBISM, EDWABD, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
A Treatise on Pharmacy : designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. 

No thorough-going pharmacist will fail to possess 
himself of so useful a guide to practice, and no 



physician who properly estimates the value of an 
accurate knowledge of the remedial agents em- 
ployed by him in daily practice, so far as their 
miscibility, compatibility and most effective meth- 
ods of combination are concerned, can afford to 
leave this work out of the list of their works of 
reference. The country practitioner, who must 
always be in a measure his own pharmacist, will 
find it indispensable.— Louisville Medical News, 
March 29, 1884. 

This well-known work presents itself now based 
upon the recently revised new Pharmacopoeia. 



Each page bears evidence of the care bestowed 
upon it, and conveys valuable information from 
the rich store of the editor's experience. In fact, 
all that relates to practical pharmacy — apparatus, 
processes and dispensing— has been arranged ana 
described with clearness in its various aspects, so 
as to afford aid and advice alike to the student and 
to the practical pharmacist. The work is judi- 
ciously illustrated with good woodcuts — American 
Journal of Pharmacy, January, 1884. 

There is nothing to equal Parrish's Pharmacy 
in this or any other language.— London Pharma- 
ceutical Journal. 



HEB3IAWJST, Dr. L., 

Professor of Physiology in the University of Zurich. 
Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 
illustrations. Cloth, $1.50. 

BBUCE, J. MITCHELL, M. &., F. B. C. P., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. 

Materia Medica and Therapeutics. An Introduction to Rational Treat- 
ment. Fourth edition. In one pocket-size 12mo. volume of 591 pages. Limp cloth, 
$1.50. See Students' Series of Manuals, page 4. 

GBIFFITH, BOBEBT EGLE8FIELD, M. D. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
sits. Third edition, thoroughly revised, with numerous additions, by John M. Maisch, 
Phar.D., Professor of Materia Medica and. Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 



12 Lea Brothers & Co.'s Publications— Mat. Med., Therap. 



STLLLE, A., II. !>., LL. &., & MAISCM, J. M., Bhar. L>.? 



Professor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



Prof, oj- Mat. Med. and Botany in Phila^ 
College of Pharmacy, Sec'yto the Ameri- 
can Pharmaceutical Association. 



NEW (FOURTH) EDITION. 

The National Dispensatory. 

CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF 

MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPCEIAS OF THE 

UNITED STATES, GREAT BRITAIN AMD GERMANY, WITH NUMEROUS 

REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. 

In one magnificent imperial octavo volume of 1794 pages, with 311 elaborate 
engravings. Price in cloth, $7.25 : leather, raised bands, $8.00; very handsome hall- 
Russia, raised bands and open back , $9.00. 

*#* This work will be furnished with Patent Ready Reference Thumb-letter Index for $1.00 
in addition to the price in any style of binding. 

In this new edition of The National Dispensatory, all important changes in the 
recent British Pharmacopoeia have been incorporated throughout the volume, while in 
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical 
novelties which have been established in professional favor since the publication of the 
third edition two years ago. Detailed information is thus given of the following among 
the many drugs treated: Anti pyrin, Cocaine Hydrochlorate, Cascara Sagrada, Fabiana, 
Franciscea, various new Glycerins, Gymnocladus, Hydroquinon, Hypnone, lodol, Jaca- 
randa, Lanolin, Menthol, Phormium, Sulphophenol, Thallin and Urethan. In this 
edition, as always before, The National Dispensatory may be said to be the represent- 
ative of the most recent state of American, English, German and French Pharmacology, 
Therapeutics and Materia Medica. 



The National Dispensatory is so well and favor- 
ably known on both sides of the Atlantic that 
scarcely anything else is left to the reviewer than 
to call attention to the fact that another edition 
of this valuable work has made its appearance. 
This last edi ion surpasses even its predecessors 
in thoroughness and accuracy. The fact that in 
1884, when the third edition was published, no 
revision of the British Pharmacopoeia had been 
made for seventeen years, has necessitated a 
thorough going over of the whole work in order 
that references might correspond to the la^t re- 
vision of the work of our British cousins. In 
addition to these changes is a fairly full resume, in 
the form of addenda, of the more important drugs 



which have come into general use in the last twa 
or three years. — The American Journal of the Med- 
ical Sciences, April, 18x7. 

We think it a matter for congratulation that the 
profession of medicine and that of pharmacy have 
shown such appreciation of this great work as to call 
for four editions within the comparatively brief 
period of eight years. The matters with which it 
deals are of so practical a nature that neither the 
physician nor the pharmacist can do without the 
latest text- books on them, especially those that are 
so accurate and comprehensive as this one. The 
book is in every way creditable both to the authors 
and to the publishers. — New York Medical Journal, 
May 21, 1887. 



EDE8, ROBERT T. 9 M. B. 9 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Materia Mediea and Therapeutics. In one octavo volume 

of 544 pages. Cloth, $3.50 ; leather, $4.50. 

The treatise will be found to be concise and 

practical, bringing the subject down to the latest 

developments < f therapeutics and pharmacology. 



The student and practitioner will find the book 
valuable one for reference and study, the former 
being facilitated hyafnll and excellent index.— 
St. Louis Medical and Surgical Journal, Jan. 1888. 

The present work seems destined to take a prom- 
inent place as a text-book on the subjects of which 
it treats. It possesses all the essentials which we 
expect in a b ok of its kind, such as conciseness, 
clearness, a judicious classification, and a reason- 
able degree of dogmatism. The style deserves 
the highest commendation for its dignity and 
purity of diction. The student and y-ung practi 
tioner need a safe guide in this branch of medi- 



Just ready. 

cine. Such they can find in the present author. 
Ail the newest drugs of promise are treated of. 
The clinical index at the end will be found very 
us<- ful. We heartily commend the book and con- 
gratulate the author on having produced so good 
a one.- N. Y. Medical Jou nal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
hook the practical therapeutics of the present 
day. The hook is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic, a tion, and such a classification will 
always meet the approval of the student. The rela- 
tive importance of different remedies is indicated 
by the space devoted to each, and by the use of 
larger type in the titles of the more important 
articles.— Pharmaceutical Era, Jan. 1888. 



FARQVHARSOJST, ROBERT, M. D. 9 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A Guide to Therapeutics and Materia Medica. Third American edition, 
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by 
Frank Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25. 



STILLE, ALFRED, M. 1). 9 LL. 1). 9 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. _ Fourth edition,, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages, 
Cloth, $10.00 ; leather, $12.00 ; very handsome half Russia, raised bands, $13.00. 



Lea Brothers & Co.'s Publications — Pathol., Histol. 



13 



COATS, JOSEPH, M. D., F. F. P. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise Oil Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $8.50. 

The work before us treats the subject of Path- I partmeutof medicine that is not as fully elucidated 
ology more extensively than it is usually treated I as our present knowledge will admit.— Cincinnati 



in similar works. Medical students as wel 
physicians, who desire a work for study or refer- 
ence, that treats the subjects in the various de- 
partments in a very thorough manner, but without 
prolixity, will certainly give this one the prefer- 
ence to any with which we are acquainted. It sets 
forth the most recent discoveries, exhibits, in an 
interesting manner, the changes from a normal 
condition effected in structures by disease, And 
points out the characteristics of various morbid 
agencies, so that they can be easily recognized. But, 
not limited to morbid anatomy, it explaius fully how 
the functions of organs are disturbed by abnormal 
conditions. There is nothing belonging to its de- 



Medical Yews, Oct. 1883. 

One of the best features of this treatise consists 
in the judicious admixture of foreign observation 
with private experience. Thus the subject is 
presented in a harmonious manner, facilitating 
the study of single topics and making the entire 
volume profitable and pleasant reading. The 
author includes in his descriptions, general 
pathology as well as the special pathological histol- 
ogy of the different systems and organs. He has 
succeeded in offering to students and practition- 
ers a thoroughly acceptable work. — Medical Record, 
Dec. 22, 1883. 



GREEJV, T. HENRY, 31. D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 

Pathology and Morbid Anatomy. New (sixth) American from the seventh 
revised and enlarged English edition. In one very handsome octavo volume of about 
500 pages, with about 150 fine engravings. Preparing. 

A notice of the previous edition is appended. 
The fact that this well-known treatise has sol No work in the English language is so admirably 
rapidly reached its sixth edition is a strong evi- i adapted to the wants of the student and practi 



dence of its popularity. The author is to he con- 
gratulated upon the thoroughness with which he 
Has prepared this work. It is thoroughly abreast 
with all the most recent advances in pathology. 



doner as this, and we would recommend it most 
earnestly to every one. — Nashville Journal of Medi- 
cine and Surgery, Nov. 1884. 



WOODHEAD, G. SIMS, M. D., F. R. C. P. E., 

Demonstrator of Pathology in the University of Edinburgh. 
Practical Pathology. A Manual for Students and Practitioners. In one beau- 
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 

It forms a real guide for the student and practi- I the actual images seen under the microscope. 
tioner who is thoroughly in earnest in his en- The author merits all praise for having produced 

a ^aluahle work. — Medical Record, May 31, 1884 

We would heartily recommend it to any student 
who desires to acquaint himself with the subject. 
In the matter we can find no hing to criticise. 
Every point is explained with perfect satisfaction, 
so that the merest tyro may understand. — Physician 
and Surgeon, December, 1883. 



deavor to see for himself and do for himself. To 
the laboratory student it will be a helpful com- 
panion, and all those who may wish to familiarize 
themselves with modern methods of examining 
morbid tissues are strongly urged to provide 
themselves with this manual. The numerous 
drawings are not fancied pictures, or merely 
schematic diagrams, but they represent faithfully 



SCHAFER, EDWARD A., F. R. S., 

Assistant Professor of Physiology m University College, London. 

The Essentials of Histology. In one octavo volume of 246 pages, with 
281 illustrations. Cloth. $2.25. 



This admirable work was greatly needed. To 
those who are familiar with the author's former 
"Course of Practical Histology," the book needs 
no recommendation. It has been written with the 
object of supplying the student with directions 



an elementary text-book of histology, comprising 
all the essentia 1 fa^ts of the science, but omitting 
unimportant d* tails. The author has recom- 
mended onlv those methods upon which long ex- 
perience has proved that full dependence can be 



for the microscopical examination of the tissues, j p!ar-ed. The strict observance of this plan 
which are given in a clear and understandable l mits of no doubt, and m-ikes the work eminently 
way. Although especially adapted for laboratory i satisfactory. — The Physician and Surgeon, July, 1887. 
work, at the same time it is intended to serve as \ 



KLEIN, E„ M. D., F. R. S., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew 's Hosp., London. 
Elements of Histology. Third edition. In one pocket-size 12mo. volume of 
360 pages, with 181 illus. Limp cloth, $1.50. See Student?? Series of Manuals, page 4. 



This little volume, originally intended by its 
able author as a manual for medical students, 
contains much valuable information, systematic- 
ally arranged, that will be acceptable to the 
general practitioner. It gives a graphic and lucid 
escription of every tissue and organ in the hu- 



man body; and, while small in size, it is full to 
overflowing with important facts in regard to these 
multiform and complex structures. We know of 
no book of its size that will prove of greater va'ue 
to medieal students and practitioners of medi- 
cine. — The Southern Practitioner Nov. 1883. 



PEPPER, A. J., M. B., M. S., F. R. C. S., 

Surgeon and Lecturer at St. Mary's Hospital, London. 
Surgical Pathology. In one pocket-size 12mo. volume of 511 pa^es, with 81 
illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. 

It is not pretentious, but it will serve exceed- 
ingly well as a book of reference. It embodies a 
great deal of matter, extending over the whole 
field of surgical pathology. Its form is practical, 
Its language is clear, and the information set 
forth is well-arranged, well-indexed and well- 



illustrated. The student will find in it nothing 
that is unnecessary. The list of subjects covers 
the whole range of surgery. The book supplies a 
very manifest want and should meet with suc- 
cess. — New York Medical Journal, May 31, 1884. 



Cornil and Ranvier's Pathological Histology. — Translated by E. O. 
Shakespeare, M. D., and. J. Henry C. Simes, M. D. Octavo, 800 pp., 360 illustrations. 



14 



Lea Brothers & Co.'s Publications — Practice of Med, 



FLINT, AUSTIN, M. D., LI. I). 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- 
vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, "N. Y. In one very handsome 
octavo volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6.50; very 
handsome half Russia, raised bands, $7.00. 



A new edition of a work of such established rep- 
utation as Flint's Medicine needs but few words to 
commend it to notice. It may in truth be said to 
embody the fruit of his labors in clinical medicine, 
ripened by the experience of a long life devoted to 
its pursuit. America may well be proud of having 
produced a man whose indefatigable industry and 
gifts of genius have done so much to advance med- 
icine ; and all English-reading students must be 
frateful for the work which he has left behind him. 
t has few equals, either in point of literary excel- 
lence, or of scientific learning, and no one can 
study its pages without being struck by the lu- 
cidity and accuracy which characterize them. It 
is qualities such as these which render it so valu- 
able for its purpose, and give it a foremost place 
among the text-books of this generation. — The 
London Lancet, March 12, 1887. 

No text-book on the principles and practice of 
medicine has ever met in this country with such 



general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this ( vast country the book that will be most likely 
to be found in the office of a medical man, whether 
in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art. — Cincinnati Medical News, Oct. 1886. 



MAFTSHOMNE, MFNMT, M. D., LL. &., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 
Within the compass of 600 pages it treats of the j this one; and probably not one writer in our day 
history of medicine, general pathology, general \ had a better opportunity than Dr. Hartshorne for 
symptomatology, and physical diagnosis (including j condensing all the views of eminent practitioners 
laryngoscope, ophthalmoscope, etc.), general ther- I into a 12mo. The numerous illustrations will be 
apeutics, nosology, and special pathology and prac- | very useful to students especially. These essen- 
tice. There is a wonderful amount of information j tials, as the name suggests, are not intended to 
contained in this work, and it is one of the best supersede the text-books of Flint and Bartholow, 



of its kind that we have seen.— Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment.— Chicago 
Medical Journal and Examiner, April, 1882. 



BMISTOWF, JOHN SYEM, M. D., F. _&. C. F., 

Physician and Joint Lecturer on Medicine at St. Thomas' Hospital, London. 

A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 

The book is a model of conciseness, and com- j and practice, as skin diseases, syphilis and insan- 
bines, as successfully as one could conceive it to ity, but they will not be objected to by readers, as 
be possible, an encyclopaedic character with the I he has studied them conscientiously, and drawn 
smallest dimensions. It differs from other admi- j from the life.— Medical and Surgical Reporter, De- 
rable text-books in the completeness with which | cember 20, 1879. 



it covers the whole field of medicine. — Michigan 
Medical News, May 10, 1880. 

His accuracy in the portraiture of disease, his 
care in stating subtle points of diagnosis, and the 
faithfully given pathology of abnormal processes 

have seldom been surpassed. He embraces many ] its usefulness to American readers. — Buffalo Med- 
diseases not usually considered to belong to theory | ical and Surgical Journal, March, 1880. 



The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and 
concise. The additions made by Dr. Hutchinson 
are appropriate and practical, and greatly add to 



WATSON, SIM TH03IAS, M. D. 9 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
In two large octavo volumes oi 1840 pages. Cloth, $9.00 ; leather, $11.00. 



LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50. 

A TREATISE ON FEVER. By Robebt D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. 



LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and hand- 
some octavo volumes of 1468 pp. Cloth, $7.00. 



A CENTURY OF AMERICAN MEDICINE, 1776—1876. By Drs. E. H. Clabke, 
Biselow, S. D. Gboss, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 pages. 



H. J. 



Lea Brothers & Co/s Publications — System of Med, 



15 



For Sale by Subscription Only. 



A System of Practical Medicine. 

BY AMERICAN AUTHORS. 

Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND QF 
CXINICAD MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 
Hospital of the University of Pennsylvania. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is just ready. 
Price per volume, cloth, §5; leather, §6 ; half Russia, raised bands and open back, $7. 



In this great work American medicine is for the first time reflected by its worthiest 
teachers, and presented in the full development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has been 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus will be sent to any address on application to the publishers. 

These two volumes bring this admirable work I physicians who are acquainted with all the varie- 
to a close, and fully sustain the high standard | ties of climate in the United States, the character 
reached by the earlier volumes ; we have only i of the soil, the manners and customs of the peo- 
therefore to echo the eulogium pronounced upon ! 
them. We would warmly congratulate the editor 
and his collaborators at the conclusion of their 
laborious task on the admirable manner in which, 
from first to last, they have performed their several 
duties. They have succeeded in producing a 
work which will long remain a standard work of 
reference, to which practitioners will look for 

fuidance, and authors will resort to for facts, 
'rom a literary point of view, the work is without 
any serious blemish, and in respect of production, 
it has the beautiful finish that Americans always 
give their works.— Edinburgh Medical Journal, Jan. 
1887. 

* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. ■ 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- j 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, July 26, 1886. 

This huge volume forms a fitting close to the 
great system of medicine which in so short a time 
has won so high a place in medical literature, and 
has done such credit to the profession in this 
country. Among the twenty-three contributors 
are the names of the leading neurologists in 
America, and most of the work in the volume is of 
the highest order. — Boston Medical and Surgical 
Journal, July 21, 1887. 

We consider it one of the grandest works on 
Practical Medicine in the English language. It is 
a work of which the profession of this country can 
feel proud. Written exclusively by American 



pie, etc., it is peculiarly adapted to the wants 
of American practitioners of medicine, and it 
seems to us that every one of them would desire 
to have it. It has been truly called a "Complete 
Library of Practical Medicine," and the general 
practitioner will require little else in his round 
of professional duties.— Cincinnati Medical News, 
March, 1886. 

Each of the volumes is provided with a most 
copious index, and the work altogether promises 
to be one which will add much to the medical 
literature of the present century, and reflect great 
credit upon the scholarship and practical acumen 
of its authors. — The London Lancet, Oct. 3, 1885. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 
lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome 
of American brains, and is marked throughout 
by much of the sturdy independence of thought 
and originality that is a national characteristic. 
Yet nowhere is there lack of study of the most 
advanced views of the day. — North Carolina Medi- 
cal Journal, Sept. 1886. 



16 



Lea Brothers & Co.'s Publications — Clinical Med., etc. 



FOTBLEBGILL, J. M., M. D., Edin,. M. M. C. P., Lond., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New (third) edition. In one octavo volume of 661 pages. Cloth, $3.75 • leather 
$4.75. Just ready. 



Dr. Fothergill is always interesting and instruct- 
ive, and in this standard work he shows his 
peculiar power as a writer on therapeutics to the 
best advantage. Everything he undertakes is 
done conscientiously. The book well sustains 
the favorable impression which it created at the 
beginning of its career, and in its present im- 
proved form it will be welcomed more than ever 
by the busy practitioner and the scientific student 
of medicine.— The Medical News, July 23, 1887. 

To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 
between the two clearly stated, cannot fail to prove 
a great convenience to many thoughtful but busy 
physicians. The practical value of the volume is 



greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition.— Nero York Medical Journal. 
June 11, 1887. 

This is a wonderful book. If there be such a 
thing as "medicine made easy," this is the work 
to accomplish this result. It imparts information 
so agreeably, so smoothly, that the reader almost 
thinks as he lays the book down that he "knew 
that before," when in reality he did not, or else he 
could before have reconciled facts which now 
become clear as daylight. The author deals with 
the " Principles of Therapeutics " the study of 
which will give great vantage to the physician.— 
Virgin'a Medical Monthly, June, 1887. 



MEYJSTOLDS, J. MUSSELL, M. &., 

Professor of the Principles and Practice of Medicine in University College, London. 
A System of Medicine. With notes and additions by Henry Hartshorne, 
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Russia, raised bands, 
$6.50. Per set, cloth, $15; leather, $18; half Russia, $19.50. Sold only by subscription. 

STILLE, AJLFBED, M. I)., LL. !>., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Cholera : Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. 



FINEAYSON, JAMES, M. D., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of 
the Female Organs ; Dr. Robertson on Insanity ; Dr. Gemmell on Physical Diagnosis ; 
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- 
taking, Family History and Symptoms of Disorder in the Various Systems. New edition. 
In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 

The profession cannot but welcome the second 
edition of this very valuable work of Finlayson 
and his collaborators. The size of the book has 
been increased and the number of illustrations 
nearly doubled. The manner in which the sub- 



ject is treated is a most practical one. Symptoms 
alone and their diagnostic indications form the 
basis of discussion. The text explains clearly and 
thoroughly the methods of examination and the 
conclusions to be drawn from the physical signs. — 
The Medical News, April 23, 1887. 

This manual is one of the most complete and 
perfect of its kind. It goes thoroughly into the 
question of diagnosis from every possible point. 
It must l^ad to a thoroughness of observation, an 
examination indetailof every scientific appliance, 



and a study of means to the end whi^h cannot 
fail in laying an excellent foundation for the 
student for future success as an able diagnostician. 
—Medical Record, August 13, 1887. 

The second edition of this manual is a very 
considerable improvement upon the first. Much 
new matter has been introduced and the work has 
been brought up to the present time in all respects. 
As it stands it is one of the best manuals of diag- 
nosis in the Knglish language for beginners. The 
whole work is so complete and so simply written, 
and yet contains such an amount of valuable 



of every practitioner.- 
July 23, 1887. 



-New York Medical Journd 



a\ 



FENWICK, SAMUEL, M. D., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25. 

HABEBSHOW, S. O., M. I)., 

Senior Physician to and late Led. on Principles and Practice of Med. at Quy's Hospital, London. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, CEsophagus, Csecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 

TAJS1TEB, THOMAS 1IAWKES, M. D. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Revised and enlarged by Tilbury Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 



Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 17 



BABTHOLOW, BOBEBTS, A. M., M. JD., LL. I)., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 
308 pages, with 110 illustrations. Cloth, $2.50. 

The fact that this work has reached its third edi- 
tion in six years, and that it ha* been kept fully 
abreast with the increasing u*e and knowledge of 
electricity,demonstrates its claim to be considered 
a practical treatise of tried value to the profession. 
The matter added to the present edition embraces 
the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner — The Medical News, May 14, 1887. 

This "practical treatise on the applications of 
electricity to medicine and surgery" has grown to 
be so important a work that every practitioner 



should read it, especially when it is recalled what 
possibilities lie in the path of the further study of 
the therapeutics of electricity. Dr. Bartholow has 
here presented the profession with a concise work 
that, beginning with elementary descriptions and 
principles, gradually grows, page by page, into a 
magnificently practical treatise, describing opera- 
tions in detail, and giving records of successes 
that prove electricity to be marvellous as a curative 
agent in many forms of disease. The doctor can- 
not now do better than to possess himself of Dr. 
Bartholow's treatise, just as it is. — Virginia Medi- 
cal Monthly, June, 1887. 



BICHABDSON, B. W. 9 M.I)., LL. &., F.B.S., 

Fellow of the Royal College ot Physicians, london. 

Preventive Medicine. In one octavo volume ot 729 pages. Cloth, $4; leather, 
$5; very handsome half Russia, raised bands, $5.50. 

tive collection of data upon the diseases common 
to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly; the discussion of 



Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
intelligent and practical form. There is perhaps 
no similar work written for the general public 
thatcontains such a complete, reliable and instruc- 



tive question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable.— The 
American Journal of the Medical Sciences, April, 1884. 



HABTSHOBNE, HENBY, M. D. 9 LL. J>. 9 

Formerly Professor of Hygiene in the University of Pennsylvania, and Professor of Physiology and 
Diseases of Children in the Woman's Medical College of Pennsylvania. 

A Household Manual of Medicine, Surgery, Nursing and Hygiene: 

For Daily Use in the Preservation of Health and Care of the Sick and Injured, with an 
Introductory Outline of Anatomy and Physiology. In one very handsome royal octavo 
volume of 946 pages, with 8 plates and 283 engravings. Cloth, $4.00 ; very handsome 
full red leather, $5.00. 

THE YEAB-BOOK OF TREATMENT FOB 1887. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 341 pages, bound in limp cloth, $1.25. Just ready. 



THE YEAB-BOOK OF TBEATMEWT FOB 1886. 

Similar to that of 1887 above. 12mo., 320 pages. Limp cloth, $1.25. 

every practitioner, whether he be a general one or 
a specialist. It is a book to be kept on the office 
table for continuous reference. An excellent in- 
dex to subjects, as well as to authors quoted, is 
appended. — Virginia Medical Monthly, April, 1887. 



This "review" includes every department of 
medical and surgical as well as obstetrical practice. 
It attempts nothing in the way of etiology, diag- 
nosis or symptoms, but limits itself to the ad- 
vances made in the treatment of diseases, injuries, 
etc. The work seems to us to be invaluable to 



#*%. For special commutations with periodicals see page 3. 

SCHBEIBEB, L>B. JOSEPH. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. Just ready. Cloth, $2.75. 

The present volume will do much to establish 
mechanical therapeutics upon a scientific basis. 
The work is a very welcome addition to the library, 
and we heartily recommend it to our readers 



a step in the right direction. — New York Medical 
Journal, July 16, 1887. 
As a thorough and satisfactory exposition of the 



science of mechanical therapeutics, adapted to 
the use of the general practitioner, this volume 
leaves nothing to be desired. The text is fully 
illustrated by well-drawn woodcuts, leaving no 
room for obscurity in the description of the vari- 
ous manipulations recommended. — Atlanta Medi- 
cal and Surgical Journal, Aug. 1887. 



STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Frank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, 81.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth, $2.50. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 
M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, $2.75. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 



18 Lea Brothers & Co.'s Publications — Throat, Lungs, Heart. 

FLINT, AUSTIN, M. !>., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. 

A. Manual of Auscultation and Percussion; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fourth edition. In one 
handsome royal 12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75. 

This admirable little book is too well known to \ ciated. We ourselves have used a former edition 
require any extended notice. That a third and j as a text-book in teaching the physical examina- 



large edition has been exhausted in little more 
than two years, is evidence that the book is appre- I 



tion of the chest, and can consequently speak from 
experience.— Boston Med. and Sur. Jour., Feb. 11,'86. 



BY THE SAME AUTHOR. 

Physical Exploration of the Lungs by Means of Auscultation and 
Percussion. Three lectures delivered before the Philadelphia County Medical Society^ 
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. 

A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. 
Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 



BROWNE, LENNOX, E. R. C. S., E., 

Senior Physician to the Central London Throat and Ear Hospital. 

A Practical Guide to Diseases of the Throat and Nose, including 
Associated Affections of the Ear. With 120 illustrations in color, and 200 en- 
gravings on wood designed and executed by the Author. New (second) and enlarged 
edition. In one imperial octavo volume of about 600 pages. Cloth, $6. Just ready. 

Among the points to which we would especially j In this edition the letter- press has been trebled, 
draw the attention of the practitioner, is the sys- I the engravings have been quadrupled, and twenty- 
tem followed in describing the symptoms and j two new colored illustrations have been added, 
methods of treatment in the various forms of j We can cordially recommend all our readers to 
throat disease, the very valuable record of typical | procure this work and avail themselves of the 
cases culled from the author's practice, and a rich treasures of practical experience therein 
valuable appendix of formulse useful in treatment, collected. — Provincial Medical Journal, Dec. 1, 1887. 

GROSS, S. D., M.D., LL.JD., D.C.L. Oxon., LL.JD. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 
octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 

COHEN, J. SOLIS, M. L>., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 

SELLER, CARL, M. I)., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume 
of 294 pages, with 77 illustrations. Cloth, $1.75. 

BROADBENT, W. M., M. JD., E. R. C. P., 

Physician to and Lecturer on Medicine at St. Mary's Hospital. 
The Pulse. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. 



FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 476 pages. Cloth, $3.50. 



SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 



8LADE ON DIPHTHERIA ; its Nature and Treat- j its Nature, Varieties and Treatment. With an 

ment, with an account of the History of its Pre- I analysis of one thousand cases to exemplify its 

valence in various Countries. Second and revised I duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 
edition. In one 12mo. vol., pp. 158. Cloth, $1.25. JONES' CLINICAL OBSERVATIONS ON FUNC- 

WALSHE ON THE DISEASES OF THE HEART | TIONAL NERVOUS DISORDERS. Second Am- 

A.ND GREAT VESSELS. Third American edi- ' erican edition. In one handsome octavo volume 

tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. of 340 pages. Cloth, $3.25. 



Lea Brothers & Co.'s Publications — Nerv. andMent. Dis., etc. 19 
BOSS, JAMBS, M.D., F.B. C.P., LL.I>., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. In one octavo 
volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. 

This admirable work is intended for students of ' the department of medicine of which it treats, 
medicine and for such medical men as have no time Dr. Ross holds such a high scientific position that 
for lengthy treatises. Inthe present instance the any writings which bear his name are naturally 
duty of arranging the vast store of material at the expected to have the impress of a powerlui intel- 
disposal of the author, and of abridging the de- iect. In every part this handbook merits tne 
scription of the different aspects of nervous dis- ; highest praise, and will no doubt be found of the 
eases, has been performed with singular skill, and greatest value to the student as well as to the prac- 
the result is a concise and philosophical guide to titioner.— Edinburgh Medical-Journal, Jan. 1887. 

MITCHELL, S. WEIR, M. L>., 

Physician to Ortlwpoedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. 

Lectures on Diseases of the Nervous System; Especially in Women. 
Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. 

No work in our language develops or displays I teachings the stamp of authority all over the 
more features of that many-sided affection, hys- ; realm of medicine. The work, although written 
teria, or gives clearer directions for its differen- ! by a specialist, has no exclusive character, and 
tiation, or sounder suggestions relative to its \ the general practitioner above all others will find 
general management and treatment. The book its perusal profitable, since it deals with diseases 
is particularly valuable in that it represents in which he frequently encounters and must essay 
the main the author's own clinical studies, which to treat. — American Practitioner, August, 1885. 
have been so extensive and fruitful as to give his | 

HAMILTON, ALLAN McLAWE, M. L>., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. 7. 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 
When the first edition of this good book appeared characterized this book as the best of its kind in 
we gave it our emphatic endorsement, and the any language, which is a handsome endorsement 
present edition enhances our appreciation of the from an exalted source. The improvements in the 
book and its author as a safe guide to students of new edition, and the additions to it, will justify its 
clinical neurology. One of the best and most purchase even by those who possess the old.— 
critical of English neurological journals, Brain, has Alienist and Neurologist, April, 1882. 

TTJKE, JOAJNIEL HACK, M. L>., 

Joint A uthor of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with 
two colored plates. Cloth, $3.00. 

It is impossible to peruse these interesting chap- I method of interpretation. Guided by an enlight- 
ters without being convinced of the author's per- ; ened deduction, the author has reclaimed for 



feet sincerity, impartiality, and thorough mental \ science a most interesting domain in psychology, 
grasp. Dr. Tuke has exhibited the requisite previously abandoned to charlatans and empirics, 
amount of scientific address on all occasions, and This book, well conceived and well written, must 
the more intricate the phenomena the more firmly commend itself to every thoughtful understand- 
has he adhered to a physiological and rational | ing. — New York Medical Journal, September 6, 1884. 



CLOTJSTON, THOMAS S., M. D., F. It. C. JP., L. M. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Charles F. Foi^om, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. 

The practitioner as well as the student will ac- i the general practitioner in guiding him to a diag- 
cept the plain, practical teaching of the author as a j nosis and indicating the treatment, especially in 
forward step in the literature of insanity. It is many obscure and doubtful cases of mental dis- 
refreshing to find a physician of Dr. Clouston's i ease. To the American reader Dr. Folsom's Ap- 
experience and high reputation giving the bed- ■ pendix adds greatly to the value of the work, and 
side notes upon which his experience has been will make it a desirable addition to every library, 
founded and his mature judgment established. ! — American Psychological Journal, July, 1884. 
Such clinical observations cannot but be useful to 

JS^fDr. Folsom's Abstract mav also be obtained separately in one octavo volume of 
108 pages. Cloth, $1.50. 

SAVAGE, GEORGE H., M. I)., 

Lecturer on Mental Diseases at G-uy's Hospital, London. 

Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. 
of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 4. 

JPLAYFJLIR, W. S., M. !>., F. It. C. JP. 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 

Blandford on Insanity and its Treatment: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. In one very handsome octavo volume. 



20 



Lea Brothers & Co.'s Publications — Surgery. 



ASSHJJRST, JOHN, Jr., M. D., 

Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. 

The Principles and Practice of Surgery. New (fourth) edition, enlarged 
and revised, in one large and handsome octavo volume of 1114 pages, with 597 illustra- 
tions. Cloth, $6 ; leather, $7 ; half Eussia, $7.50. 

As with Erichsen so with Ashhurst, its position 
in professional favor is established, and one has 
now but to notice the changes, if any, in theory 



and practice, that are apparent in the present 
as compared with the preceding edition, published 
three years ago. The work has been brought well 
up to date, and is larger and better illustrated than 
before, and its author may rest assured that it will 
certainly have a "continuance of the favor with 
which it has heretofore been received."— The 
American Journal of the Medical Sciences, Jan. 1886. 



Every advance in surgery worth notice, chroni- 
cled in recent literature, has been suitably recog- 
nized and noted in its proper place. Suffice it to 
say, we regard Ashhurst's Surgery, as now pre- 
sented in the fourth edition, as the best single 
volume on surgery published in the English lan- 
guage, valuable alike to the student and the prac- 
titioner, to the one as a text-book, to the other as 
a manual of practical surgery. With pleasure we 
give this volume our endorsement in full. — New 
Orleans Medical and Surgical Journal, Jan., 1886. 



GROSS, S. D., M. D., LL. D., D. C. L. Oxon., LL. D. 
Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery : Pathological^ Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15; half Russia, raised bands, $16. 

His System of Surgery, which, since its first edi- 
tion in 1859, has been a standard work in this 



Dr. Gross' System of Surgery has long been the 
standard work on that subject for students and 
practitioners. — London Lancet, May 10, 1884. 

The work as a whole needs no commendation. 
Many years ago it earned for itself the enviable 
reputation of the leading American work on sur- 
gery, and it is still capable of maintaining that 
standard. A considerable amount of new material 
has been introduced, and altogether the distin- 
guished author has reason to be satisfied that he 
has placed the work fully abreast of the state of 
our knowledge. — Med. Record, Nov. 18, 1882. 



country as well as m America, in "the whole 
domain of surgery," tells how earnest and labori- 
ous and wise a surgeon he was, how thoroughly 
he appreciated the work done by men in other 
countries, and how much he contributed to pro- 
mote the science and practice of surgery in his 
own. There has been no man to whom America 
is so much indebted in this respect as the Nestor 
of surgery. — British Medical Journal, May 10, 1884. 



JDRUITT, ROBERT, M. R. C. $., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
ley Boyd, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illustra- 
tions. Cloth, $4 ; leather, $5, 

Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text- book to a very large extent. Dur- 
ing the late war in this country it was so highly 
appreciated that a copy was issued by the Govern- 
ment to each surgeon. Th-* present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. Cincinnati Medical 
News, September, 1887. 



It is essentially a new book, rewritten from be- 
ginning to end. The editor has brought his work 
up to the latest date, and nearly every subject on 
whirh the student and practitioner would desire 
to consult a surgical volume, has found its pla<'.e 
here. The volume closes with about twenty pages 
of formulae, covering a broad range of practical 
therapeutics The student will find that the new 
Druitt is to this generation what the old one was 
to the former, and no higher praise need be 
accorded to any volume. — North Carolina Medical 
Journal, October, 1887. 



BALL, CHARLES B., M. Ch., Dub., F. R. C. S. E., 

Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. 

Diseases of the Rectum and Anus. In one 12mo. volume of 417 pag-es, 
with 54 engravings and 4 colored plates Cloth, $2.25. Just ready. See Series of Clinical 
Manuals, pasre 4. 



It is a pleasure to read an exhaustive and well- 
arranged book, such as the one before us. It 
covers all the ground, and yet is written in aterse 
and eoncise style that makes it exceedingly good 
reading. The work is far in advance of the ordi- 
nary text- book on this specialty. It is very com- 



plete, and the matter is all of practical importance 
and well arranged. The writer has done for rectal 
surgery what Treves in the companion volume 
has done for intestinal obstruction, and both 
works are alike creditable. — N. Y. Medical Journal, 
Jan. 28, 1888. 



GIBNJEY, v. jp., m. d., 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopsedic Surgery. For the use of Practitioners and Students. In one hand- 
some octavo volume, profusely illustrated. Preparing. 

ROBERTS, JOHN B., A. M., M. D., 

Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. 

The Principles and Practice of Modern Surgery. For the use of Students 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 
500 pages, with many illustrations. Preparing. 



BELLAMY, EDWARD, F. R. C. 8., 

Surgeon and Lecturer on Surgery at Charing Cross Hospital, London. 
Operative Surgery. Shortly. See Students' Series of Manuals, page 4. 



Lea Brothers & Co.'s Publications— Surgery. 



21 



ERICHSEW, JOMJSr E., F. R. S., F. R. C. $., 

Professor of Surgery in University College, London, etc. 
The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 
beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. 
Cloth, $9; leather, raised bands, $11; half Russia, raised bands, $12. 



In noticing the eighth edition of this well- 
known work, it would appear superfluous to say 
more than that it has, like its predecessors, been 
brought fully up to the times, and is in conse- 
quence one of the best treatises upon surgery that 
has ever been penned by one man. We have al- 
ways regarded "The Science and Art of Surgery" 
as one of the best surgical text-books in the 
English language, and this eighth edition only 
confirms our previous opinion. We take great 
pleasure in cordially commending it to our read- 
ers.— The Medical News, April 11, 1885. 

After being before the profession for thirty 



years and maintaining during that period a re- 
putation as a leading work on surgery, there is not 
much to be said in the way of comment or criti- 
cism. That it still holds its own goes without say- 
ing. The author infuses into it his large experi- 
ence and ripe judgment. Wedded to no school, 
committed to no theory, biassed by no hobby, he 
imparts an honest personality in his observations, 
and his teachings are the rulings of an impartial 
judge. Such men are always safe guides, and their 
works stand the tests of time and experience. 
Such an author is Erichsen, and such a work is his 
Surgery.— Medical Record, Feb. 21, 1885. 



BUY ANT, THOMAS, F. R. C. S., 

Surgeon and Lecturer on Surgery at Guy's Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, - $6.50 ; leather, $7.50; half Russia, $8.00. 

The fourth edition of this work is fully abreast i books for the medical student. Almost every 
of the times. The author handles his subjects | topic in surgery is presented in such a form as to 



with that degree of judgment and skill wnich is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 
place the work among the highest order of text- 



enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical. — Chicago Medical Journal and Examiner t 
April, 1886. 



TREVES, FREDERICK, F. R. C. S., 

Hunterian Professor at the. Royal College of Surgeons of England. 
A Manual of Surgery. In Treatises by Various Authors. In three 12mo. 
volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See 
Students' Series of Manuals, page 4. 



We have here the opinions of thirty-three 
authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 
the salient points and the beginnings of new sub- 
jects are always printf-d in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance. — Cin- 
cinnati Lancet-Ciinic, August 21, 1886. 

The hand of Mr. Treves is evident throughout 



in the choice, arrangement and logical sequence of 
the subjects. Kvery topic, as far as observed, is 
treated with a fulness of essential detail, which is 
somewhat surprising. Anoihercharacteristio of the 
work is the well-nigh universal acceptance of mod- 
ern and progressive views of pathology and treat- 
ment. The entire work is conceived ami executed 
in a scientific spirit. It contains the bone and mar- 
row of modern surgery. — Annals of Surgery, Oct. 



BUTLIW, MEJSTRY T., F. R. C. 8., 

Assistant Surgeon to St. Bartholomew'' s Hospital, London. 
Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored 
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 4. 



The language of the text is clear and concise. 
The author has aimed to state facts rather than to 
express opinions, and has compressed within the 
compass of this small volume the pathology, etiol- 
ogy, etc., of diseases of the tongue that are incon- 



veniently scattered through general works on sur- 
gery and the practice of medicine. The physician 
and surgeon will appreciate its value as an aid and 
guide. — Physician and Surgeon, Sept. 1886. 



TREVES, FREDERICK, F. R. C. S., 

Surgeon to and Lecturer on Surgery at the London Hospital. 

Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 6Q 
illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 4. 

A standard work on a subject that has not been 
so comprehensively treated by any contemporary 
English writer. Its completeness renders a full 
review difficult, since every chapter deserves m 



nute attention, and it is impossible to do thorough 



justice to the author in a few paragraphs. Intes- 
tinal Obstruction is a work that will prove of 
equal value to the practitioner, the student, the 



pathologist, the physician and the operating sur- 
geon. — British Medical Journal, Jan. 31, 1885. 



GOULD, A. FEARCE, M. 8., M. B., F. R. C. S„ 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 
pages. Cloth, $2.00. See Students' Series of Manuals, page 4. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 316 illus Cloth, $3.76 

MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American from the last Edinburgh 
edition. In one large 8vo. vol. of 682 pages, with 
364 illustrations. Cloth, $3.75. 



•IKEY'S OPERATIVE SURGERY. In one vol. 8vo. 

of 661 patces. with 81 woodcuts Cloth. $3.25. 
MILLER'S PRINCIPLES OF SURGKRY. Fourth 

American from the third Edinburgh edition. In 

one 8vo. vol. of 638 pages, with 340 illustrations. 

Cloth, $3.75. 



22 Lea Brothers & Co.'s Publications — Surgery, Frac, Disloc. 



HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital,, London, 

A System of Surgery ; Theoretical and Practical. IN TREATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large and very handsome imperial octavo volumes containing 3137 double- 
columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully 
colored. Price per set,' cloth, $18.00 ; leather, $21.00 ; half Russia, $22.50. Sold only by 
subscription. 

HAMILTON, FRAJSTK H., M. D., II. &., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition 
thoroughly revised and much improved. In one very handsome octavo volume of 998 
pages, with 379 illustrations. Cloth, $5.50 ; leather, $6.50 ; very handsome half Russia, 
open back, $7.00. 

any lengthened review. We can only say that it 
is still unapproached as a treatise, and that it is a 
proof of the zeal and industry and great ability of 
its distinguished author.— the Dublin Journal of 
Medical Science, Feb. 1886. 

His famous treatise on Fractures and Disloca- 
tions, published first in 1860, is justly regarded as 
the best book on that subject in existence. It has 
now run through seven editions, and has been 
translated into French and German. — Medical 
Record, Aug. 14, 188G. 



It is about twenty-five years ago since the first 
edition of this great work appeared. The edition 
now issued is the seventh, and this fact alone is 
enough to testify to the excellence of it in all par- 
ticulars. Books upon special subjects do not 
usually command extended sale, but this one is 
without a rival in any language. It is essentially 
a practical treatise, and it gathers within its covers 
almost everything valuable that has been written 
about fractures and dislocations. The principles 
and methods of treatment are very fully given. 
The book is so well known that it does not require 



SMITH, STEPHEN, M. JO., 

Professor of Clinical Surgery in the University of the City of New York. 

The Principles and Practice of Operative Surgery. New (second) and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 
1005 illustrations. Cloth, $4.00 ; leather,* $5.00. Just ready. 

We have never come across a work upon surgery 
that we have considered better adapted to the 
wants of the medical man and student. It is 
replete with information of the most valuable, 
practical character, of a kind just fitted to the 
wants of the every-day practitioner. Having been 
thoroughly revised and partly rewritten, it has 
the merit of being fully abreast of the times in 
presenting the latest accepted views on all surgical 
matters. — Cincinnati Medical Neivs, March, 1887. 

This work is too well and too favorably known to 



require any words of commendation, and its mer- 
its effectually protect it from adverse criticism. 
It is a treatise upon the principles as well as the 
practice of mechanical surgery. The subject mat- 
ter is brought down to the very latest period, hence 
we shall find the work to be a faithful exponent 
of the art of surgery as practised now. Stephen 
Smith's Operative Surgery is one of the most com- 
plete works in the English language. The descrip- 
tions of operative procedures are plain. — The 
American Journal of the Medical Sciences, April, 1887. 



STIMSON, LEWIS A., B. A., M. &., 

Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical 
Faculty of the University of the City of New York, Corresponding Member of the Societe de 
Chirurgie of Paris. 

A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 



There is always room for a good book, so that 
while many works on operative surgery must be 
considered superfluous, that of Dr. Stimson has 
held its own. The author knows the difficult art 
of condensation. Thus the manual serves as a 
work of reference, and at the same time as a 
handy guide. It teaches what it professes, the 
steps of operations. In this edition Dr. Stimson 
has sought to indicate the changes that have been 



effected in operative methods and procedures by 
the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation.— British Medical Journal, Jan. 22, 1887. 



By the same Author. 
A Treatise on Fractures and Dislocations. In two handsome octavo vol- 
umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol, II., Disloca- 
tions, 540 pages, with 163 illustrations. Complete work just ready, cloth, $5.50 ; leather, 
$7.50. Either volume separately, cloth, $3.00 ; leather, $4.00. 



The author has given to the medical profession 
in this treatise on fractures what is likely to be- 
come a standard work on the subject. It is certainly 
not surpassed by any work written in the English, 
or, for that matter, any other language. The au- 
thor tells us in a short, concise and comprehensive 
manner, all that is known about his subject. There 
is nothing scanty or superficial about it, as in most 
other treatises ; on the contrary, everything is thor- 



ough. The chapters on repair of fractures and their 
treatment show him not only to be a profound stu- 
dent, but likewise a practical surgeon and patholo- 
gist. His mode of treatment of the different fract- 
ures is eminently sound and practical. We consider 
this work one of the best on fractures ; and it will 
be welcomed not only as a text-book, but also by 
the surgeon in full practice. — N. O. Medical ana 
Surgical Journal, March, 1883. 



MARSH, HOWARD, F. R. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. 

Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts 
and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 4. 

PICK, T. PICKERING, F. R. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume of 530^ pages, with 93 
illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 4. 



Lea Brothers & Co.'s Publications — Otol., Ophtnal, 



23 



BURWETT, CMARLES M., A. M., M. &., 

Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. New (second) edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

carried out, and much new matter added. Dr. 



We note with pleasure the appearance of a second 
edition of this valuable work. When it first came 
out it was accepted by the profession as one of 
the standard works on modern aural surgery in 
the English language ; and in his second edition 
Dr. Burnett has fully maintained his reputation, 
for the book is replete with valuable information 
and suggestions. The revision has been carefully 



Burnett's work must be regarded as a very valua- 
ble contribution to aural surgery, not only on 
account of its comprehensiveness, but because it 
contains the results of the careful personal observa- 
tion and experience of this eminent aural surgeon. 
— London Lancet, Feb. 21, 1885. 



VOLITZER, ADAM, 

Imperial- Royal Prof, of Aural Therap. in the Univ. of Vienna. 
A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Casseles, M. D., M. E. C. S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 
The work itself we do not hesitate to pronounce j section, and this again by the pathological physi- 



the best upon the subject of aural diseases which 
has ever appeared, systematic without being too 
diffuse on obsolete subjects, and eminently prac- 
tical in every sense. The anatomical descriptions 
of each separate division of the ear are admirable, 
and profusely illustrated by woodcuts. They are 
followed immediately by the physiology of the 



ology, an arrangement which serves to keep up the 
interest of the student by showing the direct ap- 
plication of what has preceded to the study of dis- 
ease. The whole work can be recommended as a 
reliable guide to the student, and an efficient aid 
to the practitioner in his treatment. — Boston Med- 
ical and Surgical Journal, June 7, 1883. 



JVLER, HENRY E., F. R. C. S., 

Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp. ; late Clinical AssH, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. In one handsome 
octavo volume of 460 pages, with 125 woodcuts, 27 colored plates, selections from the 
Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; 
leather, $5.50. 

NETTLESMIF, EDWARD, F. R. C. S., 

Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas* Hospital, London. 

The Student's Guide to Diseases of the Eye. New (third) edition, thor- 
oughly revised. With a chapter on the Detection of Color-Blindness, by William 
Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 
12mo. volume of 479 pages, with 164 illust., test-types and formulae. Cloth, $2. Just ready. 

In the small work before us we have combined dressed to students, but is equally suited to the 
simplicity of description with thoroughness of needs of practitioners, who will find in its pages 
instruction. It is such a book as any intelligent much valuable instruction. The style of the au- 
student can read with profit to himself. — St. Louis thor is pleasant, and the matter of his book is 
Medical and Surgical Journal, Oct. 1887. i admirable. — Medical and Surgical Reporter, Oct. 1, 

This excellent and trustworthy manual is ad- | 1887. 

JSTORRIS, W31. F., M. D., and OLIVER, CMAS. A., M. D. 

Clin. Prof, of Ophthalmology in Univ. of Pa. 
A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, 
with illustrations. Preparing. 

CARTER, R. BRVDENELL, & FROST, W. ADAMS, 

F, R, C S,, F, R, C 8,f 



Ophthalmic Surgeon to and Lecturer on Oph- 
thalmic Surgery at St. George's Hospital, 
London. 



Assistant Ophthalmic Surgeon to and Joint 
Lecturer on Ophthalmic' Surgery at St. 
George's Hospital, London. 



Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, 
color blindness test, test-types and dots and appendix of formulae. Just ready. Cloth^ 
$2.25. See Series of Clinical Manuals, page 4. 

WELLS, J. SOELBERG, F. R. C. S., 

Professor of Ophthalmology in King's College Hospital, London, etc. 

A Treatise on Diseases of the Eye. New (fifth) American from the third 
London edition. In one large octavo volume. Preparing. 

BROWNE, EDGAR A., 

Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. 

How to Use the Ophthalmoscope. Being Elementary Instructions in Oph- 
thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 
pages, with 35 illustrations. Cloth, $1.00. 

LAURENCE AND MOON'S HANDY BOOK OF I LAWSON ON INJURIES TO THE EYE, ORBIT 
OPHTHALMIC SURGERY, for the use of Prac- AND EYELIDS : Their Immediate and Remote 
titioners. Second edition. In one octavo vol- Effects. 8 vo., 404 pp., 92 illus. Cloth, $3.50. 
ume of 227 pages, with 65 illust. Cloth, $2.75. I 



24 Lea Brothers & Co.'s Publications— -Urin. Dis., Dentistry, etc. 



BOBEBTS, WILLIAM, M. D., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

is book have made it The peculiar value and finish of the book are in 
a measure derived from its resolute maintenance 
of a clinical and practical character. It is an un- 
rivalled exposition of everything which relates 
directly or indirectly to the diagnosis, prognosis 
and treatment of urinary diseases, and possesses 
a completeness not found elsewhere in our lan- 



The previous editions of this book have made it 
so familiar to and so highly esteemed by the med- 
ical public, that little more is necessary than a 
mere announcement of the appearance of this, 
their successor. But it is pleasant to be able to 
say that, good as those were, this is still better 
In fact, we thin k it may be said to be the best book 
in print on the subject of which it treats. — The 
American Journal of the, Medical Sciences.— Jan. 1886. 



guage in its account of the different affections. — 
The Manchester Medical Chronicle, July, 1885. 



JPUBBY, CHABLES W., M. D. 

Bright's Disease and Allied Affections of the Kidneys. 
volume of 288 pages, with illustrations. Cloth, $2. 



In one octavo 



The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



short space the theories, facts and treatments, and 
going more fully into their later developments. 
On treatment the writer is particularly strong, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct., 
1886. 



MOBBIS, HENBY, M. B., F. B. C. 8., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London, 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 4. 

he took in hand. It is a full and trustworthy 
book of reference, both for students and prac- 
titioners iu search of guidance. The illustrations 
in the text and the chromo-lithographs are beau- 
tifully executed.— The London Lancet,Feb. 26, 1886. 



In this manual we have a distinct addition to 
surgical literature, which gives information not 
elsewhere to be met with in a single work. Such 
a book was distinctly required, and Mr. Morris 
has very diligently and ably performed the task 



LUCAS, CLEMENT, M. B., B. 8., F. B. C. 8., 

Senior Assistant Surgeon to Guy's Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 4. 

THOMPSON, SIM HENBY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMEBIC AN SYSTEM OF DENTISTBY. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by 
subscription only. 



As an encyclopedia of Dentistry it has no su- 
perior. It should form a part of every dentist's 
library, as the information it contains is of the 
greatest value to all engaged in the practice of 
dentistry. — American Journal of Dental Science, 
September, 1886. 

A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it — they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while the profession at large 
will receive incalculable benefit from it. — Odonto- 
graphy Journal, Jan. 1887. 



COLEMAN, A., L. B. C. P., F. B. C. S., Exam. L. JD. 8., 

Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Steelwagen, M. A., M. D., 
D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

ESMABCH, Dr. FBIEDBICH, 

Professor of Surgery at the University of Kiel, etc. 
Early Aid in injuries and Accidents. Five Ambulance Lectures. Trans- 
lated by H. R. H. Princess Christian. In one handsome small 12mo. volume of 109 
pages, with 24 illustrations. Cloth, 75 cents. 

BASHAM ON RENAL DISEASES : A Clinical I one 12mo. vol. of 304 pages, with 21 illustrations. 
Guide to their Diagnosis and Treatment. In | Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 25 

GHOSS, SAMUEL W., A. M., M. T)., LL. D., 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. New (third) edition, thoroughly revised. In one very 
handsome octavo volume of 163 pages, with 16 illustrations. Cloth, §1.50. 

We must congratulate the author that another i that it has been translated into Russian may indi- 
edition has been made necessary. The tone of; cate that it filled a void even in foreign literature, 
the book is healthy, and a cheerful prognosis is > His is a careful and physiological study of the 
given of many of the affections of which it treats. ! sexual act, so far as concerns the male, and all 
We feel confident that the book will continue to i his conclusions are scientifically reached. The 
sell on its merits. — N. Y. Med. Journal, June 18, 1887. I book has a place by itself in our literature, and 

It must be gratifying to both author and pub- j furnishes a large fund of information concerning 
lishers that large first and second editions of this | important matters that are too often passed over 
little work were so soon exhausted, while the fact I in silence. — The Medical Press, June, 1887. 



BUMSTFAD, F. J., and TAYLOR, B. W., 

M. L>., LL. L>., A. M., M. I)., 

Late Professor of Venereal Diseases Surgeon to Charity Hospital, New York, Prof, of 

at the College of Physicians and Venereal and Skin Diseases in the University of 

Surgeons, New York, etc. Vermont, Pres. of the Am. Dermatological Ass'n. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Fifth edition, revised and largely re- 
written, by Dr. Taylor. In one large and handsome octavo volume of 898 pages with 
139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75 ; leather, $5.75 ; 
very handsome half Eussia, $6.25. 

It is a splendid record of honest labor, wide I known that it would be superfluous here to pass in 
research, just comparison, careful scrutiny and [ review its general or special points of excellence. 



original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 
upon the subjects of which it treats, but also on 



The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 
plete exposition of the pathology and treatment of 
venereal diseases in the language. Admirable as a 



wnich has no equal in other tongues for its clear, model of clear description, an exponent of sound 
comprehensive and practical handling of its | pathological doctrine, and a guide for rational and 
themes. — Am. Jour, of the Med. Sciences, Jan, 1884. j successful treatment, itis an ornament to the medi- 
It is certainly the best single treatise on vene- ' cal literature of this country. The additions made 



real in our own, and probably the best in any Ian- to the present edition are eminently judicious, 
guage. — Boston Med. and Surg. Journal, April 3, 1884. from the standpoint of practical utility. — ," 
The character of this standard work is so well Cutaneous and Venereal Diseases, Jan. 1884. 



COBJYIL, V., 

Professor to the Faculty of MedAcine of Paris, and Physician to the Lour cine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery 
in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 
84 very beautiful illustrations. Cloth, $3.75. 

The anatomy, the histology, the pathology and | perusal without the feeling that his grasp of the 
the clinical features of syphilis are represented in J wide and important subject on which it treats is 
this work in their best, most practical and most a stronger and surer one. — The London Practi- 
instructive form, and no one will rise from its i tioner, Jan. 1882. 



HUTCJECLNSON, JONATHAN, F. B. S., F. B. C. 8., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. Cloth, 
$2.25. See Series of Clinical Manuals, page 4. 

Those who have seen most of the disease and j and power of observation, but of his patience and 
those who have felt the real difficulties of diagno- | assiduity in taking notes of his cases and keep- 
sis and treatment will most highly appreciate the ' ingthem in a form available for such excellent 
facts and suggestions which abound in these I use as he has put -them to in this volume.— London 
pages. It is a worthy and valuable record, not Medical Record, Nov. 12, 1887. 
only of Mr. Hutchinson's very large experience | 

GBOSS, S. L>., M. n., ll. l>., D. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gkoss, M. D. In one octavo volume of 574 
pages, with 170 illustrations. Cloth, $4.50. 

CULLFBIFB, A., & BUMSTFAD, F. J., M.D., LL.JD., 

Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physicians 

and Surgeons, New York. 

An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- 
stead, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, 
containing about 150 figures, beautifully colored, many of them the size of life. Strongly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS FORMS OF LOCAL DISEASE AFFECTING 

DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. ! PRINCIPALLY THE ORGANS OF GENERA - 

LEE'S LECTURES ON SYPHILIS AND SOME | TION. In one 8vo. vol. of 246 pages. Cloth, $2 25. 



26 Lea Brothers & Co.'s Publications— -Venereal, Skin. 

TAYLOR, ROBERT W., A.M., M.JD., 

Surgeon to Charity Hospital, New York, and to the Department of Venereal and Skin Diseases of 
the' New York Hospital. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and 
comprising 58 beautifully-colored plates with 192 figures, 65 engravings and 400 pages 
of text. Price per part, $2.50. Parts I. and II. shortly. For sale by subscription only. 
Specimen plates sent on receipt of 10 cents. 

The early appearance of this great work will mark an era in the history of its subjects. 
It will afford to all English-speaking practitioners and specialists their first opportunity 
of procuring a work in which life-like pictures of all venereal and skin diseases are 
accompanied by a text altogether satisfactory on the practical side of these troublesome 
affections. Other distinguishing features of this Atlas will be the abundance and size 
of its colored plates, and the beauty of their execution. Being chosen with a view to 
presenting typical cases rather than mere medical curiosities, they will furnish a vivid 
and ready means of recognizing the various affections as they appear in life. The text 
will be principally confined to a terse and definite statement of diagnosis and treatment, 
and it will be further illustrated by a large number of engravings executed in a size and 
style thoroughly in keeping with the nature of the work. The Atlas will be sold by 
subscription only, and in due course every member of the profession will be personally 
visited and offered an opportunity to procure this most useful addition to his working 
library. A full prospectus is now ready for distribution on application. 



KAPOSI, MORIZ, 

Of Vienna. 

The Pathology and Treatment of Diseases of the Skin. For the use 

of Practitioners and Students, Translated, with the author's permission, by W. Xavier 
Sudduth, M. D., F. K. M. S. In one octavo volume of about 600 pages, with 74 engrav- 
ings and 8 colored plates. Preparing. 

HYL>F, J. XMVIXS, A. M., M. D., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 

Practitioners. New (second) edition. In one handsome octavo volume of about 600 
pages, with 2 colored plates and 85 beautiful and elaborate illustrations. Just ready. 
Cloth, $4.50 ; leather, $5.50. 

A few notices of the previous edition are appended : 



The author has given the student and practi- 
tioner a work admirably adapted to the wants of 
each. We can heartily commend the book as a 
valuable addition to our literature and a reliable 
guide to students and practitioners in their studies 
and practice. — Am. Journ. of Med. Sci., July, 1883. 

The aim of the author has been to present to his 
readers a work not only expounding the most 
modem conceptions of his subject, but presenting 
what is of standard value. He has more especially 
devoted its pages to the treatment of disease, and 



by his detailed descriptions of therapeutic meas- 
ures has adapted them to the needs of the physi- 
cian in active practice. In dealing with these 
questions the author leaves nothing to the pre- 
sumed knowledge of the reader, but enters thor- 
oughly into the most minute description, so that 
one is not only told what should be done under 
given conditions but how to do it as well. It is 
therefore in the best sense "a practical treatise." 
That it is comprehensive, a glance at the index 
will show. — Maryland Medical Journal, July 7, 1883. 



FOX, T., M.D.,F.R.C.F.,andFOX,T.€.,R.A.,M.R.C.S. 9 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $1.25. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
one which we can strongly recommend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology.— British Medical Journal, July 2, 1883. 

We cordially recommend Fox's Epitome to those 
whose time is limited and who wish a handy 



manual to lie upon the table for instant reference. 
Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented.— The Medical News, December, 1883. 



WILSON, ERASMUS, F. R. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 



MILLIFR, THOMAS, M. JD., 

Physician to the Skin Department of University College, London. 
Handbook of Skin Diseases ; for Students and Practitioners. Second Ameri- 
can edition. In one 12mo, volume of 353 pages, with plates. Cloth, $2.25. 



Lea Brothers & Co.'s Publications — Dis. of Women. 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo^ and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Obstetrician to the Philadelphia and to the 
Maternity Hospitals, Philadelphia. In four very handsome octavo volumes of aboxit 800 
pages each, fully illustrated by wood engravings and colored plates. Volume I. of the 
Gynecology, containing 784 pages, with 201 engravings on wood and 3 colored plates, is 
now ready. Volume I. of the Obstetrics ready shortly. The subsequent volumes are to 
follow at regular intervals. Prices per volume: Cloth, $5.00 ; leather, $6.00 ; half Russia, 
$7.00. For sale by subscription only. Address the Publishers. Full descriptive circular 
free on application. 

LIST OF CONTRIBUTORS. 

HOWARD A. KELLY, M. D , 
CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., LL. D., 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M 



WILLIAM H. BAKER, M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D., 
JAMES C. CAMERON, M. D., 
HENRY C. COE, A. M., M. D., 
E. C. DUDLEY, A. B., M. D., 
EDWARD S. DUNSTER, M. D., 
B. McE. EMMET, M. D., 
GEORGE J. ENGELMANN, M. D., 
HAROLD C. ERNST, M. D., 
HENRY J. GARRIGUES, A. M., M. D., 
WILLIAM GOODELL, A. M., M. D., 
EGBERT H. GRANDIN, A. M., M. D., 
CHARLES M. GREEN, M. D., 
SAMUEL W. GROSS, M. D., 
ROBERT P. HARRIS, M. D., 
GEORGE T. HARRISON, M. D., 
BARTON C. HIRST, M. D. 
STEPHEN Y. HOWELL, M. D., 
A. REEVES JACKSON, A. M., M. D., 
W. W. JAGGARD, M. D., 
EDWARD W. JENKS, M. D., LL. D., 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement : — " It is a work of which the pro- 



D* 
D.Sc, M.A., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., . 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D., LL. D. 7 
R. A. F. PENROSE, M. D., LL. D., 
THADDEUS A. REAMY, A. M., M.*D., 
J. C. REEVE, M. D., 
WILLIAM L. RICHARDSON, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
R. STANSBURY SUTTON, A. M., M. D^ 

LL. D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE, M. D. 
which we desire now to bring to the attention of 
our readers. It, like the other, has been written 
exclusively by American physicians who are 



fession in this country can feel proud. Written | acquainted with all the characteristics of American 



exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 



people, who are well informed in regard to the 
peculiarities of American women, their manners, 
customs, modes of living, etc. As every practis- 
ing physician is called upon to treat diseases of 
females, and as they constitute a class to which 



ers of medicine, and it seems to us that every one j the familly physician must give attention, and 
of them would desire to have it." Every word cannot pass over to a specialist, we do not know of 
thus expressed in regard to the "American Sys- a work in any department of medicine that we 
tern of Practical Medicine" is applicable to the should so strongly recommend medical men gen- 
" System of Gynecology by American Authors," | erally purchasing.— Cincinnati Med. iVeit'S, July,1887„ 

THOMAS, T. GAILLABD, M. !>., 

Professor of Diseases of Women in the College of Physicians and Surgeons, N. 7. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 
illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 
The words which follow " fifth edition" are in I That the previous editions of the treatise of Dr. 
this case no mere formal announcement. The Thomas were thought worthy of translation into 
alterations and additions which have been made are i German, French, Italian and Spanish, is enough 
both numerous and important. The attraction : to give it the stamp of genuine merit. At home it 
and the permanent character of this book lie in ' has made its way into the library of every obstet- 
the clearness and truth of the clinical descriptions rician and gynecologist as a safe guide to practice, 
of diseases; the fertility of the author in thera- i No small number of additions have been made to 
peutic resources and the fulness with which the j the present edition to make it correspond to re- 
details of treatment are described: the definite cent improvements in treatment.— Pacific Medical 
character of the teaching; and last, but not least, and Surgical Journal, Jan. 1881. 
the evident candor which pervades it. — London 
Medical Times and Gazette, July 30, 1881. 



jEJDIS, ABTHJJB W., M. D., Lond., JF.B. C.P., M.B. C.8., 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather. $4.00. 

It is a pleasure to read a book so thoroughly are among the more common methods of treat- 
good as this one. The special qualities which are j ment, and yet very little is said about them in 
conspicuous are thoroughness in covering the many of the text-books. The book is one to be 
whole ground, clearness of description and con- ! warmly recommended especially to students and 
ciseness of statement. Another marked feature of ' general practitioners, who need a concise but com- 
the book is the attention paid to the details of plete resume of the whole subject. Specialists, too, 
many minor surgical operations and procedures, : will find many useful hints in its pages.— Boston 
as, for instance, the use of tents, application of Med. and Surg'. Journ., March 2, 1882. 
leeches, and use of hot water injections. These | 

BABNES, BOBEBT, M. &., E. B. C. P., 

Obstetric Physician to St. Thomas' Hospital, London, etc. 

A Clinical Exposition of the Medical and Surgical Diseases of Women, 

In one handsome octavo volume, with numerous illustrations. New edition. Preparing, 



28 



Lea Brothers & Co.'s Publications — Dis. of Women, Midwfy. 



EMMET, THOMAS ADDIS, M. D., EL. D., 

Surgeon to the Woman's Hospital, New York, etc. 

The Principles and Practice of Gynecology ; For the use of Students and 
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; 
very handsome half Russia, raised bands, $6.50. 

We are in douot whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 



Embodying, as it does, the' life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 
the privilege thus offered them of perusing the 
views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 



endeavors to represent the actual state of gynse- 

Jt 
nal, May 16, 1885. 



cological science and art. — British Medical Jour- 



No jot or tittle of the high praise bestowed upon 
the first edition is abated. It is still a book of 
marked personality, one based upon large clinical 
experience, containing large and valuable ad- 
ditions to our knowledge, evidently written not 



only with honesty of purpose, but with a conscien- 
tious sense of responsibility, and a book that is at 
once a credit to its author and to American med- 
ical literature. We repeat that it is a book to be 
studied, and one that is indispensable to every 
practitioner giving any attention to gynaecology. — 
American Journal of the Medical Sciences, April, 1885. 
The time has passed when Emmet's Gynaecology 
was to be regarded as a book for a single country 
or for a single generation. It has always been his 
aim to popularize gynaecology, to bring it within 
easy reach of the general practitioner. The orig- 
inality of the ideas compels our admiration and 
respect. We may well take an honest pride in 
Dr. Emmet's work and feel that his book can 
hold its own against the criticism of two conti- 
nents. It represents all that is most earnest and 
most thoughtful in American gynaecology. — Amer- 
ican Journal of Obstetrics, May, 1885. 



DUNCAN, J. MATTHEWS, M.D., EL. D., E. B. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

rule, adequately handled in the text-books ; others 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that they deserve to be 
widely read. — N. Y. Medical Joicrnal, March, 1880. 



MAY, CHABLES H., M. D. 

Late House Surgeon to Mount Sinai Hospital, New York. 
A Manual of the Diseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynsecologv. In one 12mo. volume of 342 pages. 
Cloth, $1.75. 

Medical students will find this work adapted to tions, and the presentation only of accepted views, 
their wants. Also practitioners of medicine will it constitutes a very satisfactory exposition of the 
find it exceedingly convenient to consult for the leading principles of gynaecology as they are un- 
purpose of refreshing their minds upon the lead- derstood at the present time. — Cincinnati Medical 
mg points of a gynaecological subject. By syste- News, Nov. 1885. 
matic condensation, the omission of disputed ques- 



HODGE, HUGHE., M. D., 

Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. 

On Diseases Peculiar to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 
pages, with original illustrations. Gloth, $4.50. 

By the Same Author. 

The Principles and Practice of Obstetrics. Illustrated with large litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in 
cloth, $14.00. Specimens of the plates and letter-press will be forwarded to any address, 
free by mail, on receipt of six cents in postage stamps. 

BAMSBOTHAM, FBANCIS H., M. D. 

The Principles and Practice of Obstetric Medicine and Surgery; 

In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., 
in the Jefferson Medical College of Philadelphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 

WINCKEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. B. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 

WEST, CHABLES, M. D. 

Lectures on the Diseases of Women. Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8yo. vol., pp. 520. Cloth. 83.50. 

CHURCHILL ON THE PUERPERAL FEVER 



AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, $2.50. 
MEIGS ON THE NATURE, SIGNS AND TREAT- 
MENT OF CHILDBED FEVER. In one 8vo. 
volume of 346 pages. Cloth, $2.00. 



Lea Brothers & Uo.'s Publications — Midwifery. 



29 



JPABYIN, THEOPHILVS, 31. B. 9 XL. !>., 

Prof, of Obstetrics and the Diseases of Women and Children m Jefferson Med. Coll , Phila. 

The Science and Art of Obstetrics. In one handsome 8vo. volume of 697 
pages, with 214 engravings and a colored plate. Cloth, $4.25 ; leather, $5.25. 

It is a ripe harvest that Dr. Parvin offers to his ] favorable for an agreeahle unfolding of the science 
readers There is no book that can be more safely and art of obstetrics. This new book is the easy 

superior of any single work among its predeces- 



recommended to the student or that can be turned 
to in moments of doubt with greater assurance of 
aid, as it is a liberal digest of safe counsel that has 
been patiently gathered.-— The American Journal 
of the Medical Sciences, July, 1887. 

There is not in the language a treatise on the 
subject whi^h so completely and intelligent!}' 
gleans the whole field of obstetric literature, giv- 
ing the reader the winnowed wheat in concise and 
well-jointed phrase, in language of exceptional 
purity and strength. The arrangement of the 
matter of this work is unique and exceedingly 



ors for the student or practitioner seeking the 
best thought of the day in this department of 
medicine. — The American Practitioner and News, 
April 2, 1887. 

This treatise maybe defined as exact, concise 
and scholarly. Parvin's distinguished position as 
a teacher, his scholarly attainments, and his 
honest endeavor to do his best by both the student 
and the physician, will secure for his treatise 
favorable recognition. — American Journal of Obstet- 
rics, May, 1887. 



BABNFS, BOBFBT, M. !>., and FANCOTJBT, M. I>. 9 

Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' Hosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology contributed by 
Prof. Milnes Marshall. In one handsome octavo volume of 872 pages, with 231 illus- 
trations. Cloth, $5 ; leather, $6. 



This system will be eagerly sought for, not only 
on account of its intrinsic merit, but also because 
the reputation which the elder Barnes, in particu- 
lar, has secured, carries with it the conviction that 
any book emanating from him is necessarily sound 
in teaching and conservative in practice. It is in- 
deed eminently fitting that a man who has done so 
much towards systematizing the obstetric art, who 
for so many years has been widely known as a capa- 



ble teacher and trusted accoucheur, should embody 
within a single treatise the system which he has 
taught and in practice tested, and which is the out- 
come of a lifetime of earn-st labor, careful obser- 
vation and deep study. The result of this arrange- 
ment is the production ol a work which rises above 
criticism and which in no respect need yield the 
palm to any obstetrical treatise hitherto published. 
— American Journal of Obstetrics, Feb. 1886. 



PLAYFAIB, W. 8., M. JD. 9 F. B. C. P., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fourth) 
American, from the fifth English edition. Edited, with additions, by Kobert P. Har- 
ris, M. D. In one handsome octavo volume of 654 pages, with 3 plates and 201 engrav- 
ings. Cloth, $4 ; leather, $5 ; half Kussia, $5.50. 

This still remains a favorite in America, not 
only because the author is recognized as a safe 
guide and eminently progressive man, but also as 
sparing no effort to make each successive edition 
a faithful mirror of the latest and best practice. 
A work so frequently noticed as the present 
requires no further review. We believe that this 
edition is simply the forerunner of many others, 
and that the demand will keep pace with the 



supply. — American Journal of Obstetrics, Nov. 1885. 
Since its first publication, only eight years ago, 
it has rapidly become the favorite text-book, to 
the practical exclusion of all others. A large 
measure of its popularity is due to the clear and 
easy style in which it is written. Few text-books 
for students have very much to boast of in this 
respect. — Medical Record. 



KING, A. F. A., 31. D. 9 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- 
sity, Washington, D. C, and in the University of Vermont, etc. 
A Manual Of Obstetrics. New (third) edition. In one very handsome 12mo. 
volume of 376 pages, with 102 illustrations. Cloth, $2.25. 

This little manual, certainly the best of its kind, bulky — it is concise. The chapters are divided with 

fully deserves the popularity which ha* made a sub-headings, which aid materially in the finding 

third edition necessary. Clear, practical, concise, of any particular subject, and the definitions are 

its teachings are so fully abreast with recent ad- clear and explicit. It fulfils its purpose admirably, 

vances in obstetric science that but few points and we know of no better work to place in the stu- 

can be criticised. — American Journal of Obstetrics, dent's hands. The illustrations are good. — Arch- 

March, 1887. ives of Gynecology, January, 1887. 

This volume deserves commendation. It is not 



BABKFB, FORDYCF, A. 31. 9 M. Z)., LL. JD. Fdin., 

Clinical Professor of Midwifery and the Diseases of Women, in the Bellevue Hospital Medical College, 
New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. 

Obstetrical and Clinical Essays. In one handsome 12mo. volume of about 
300 pages. Preparing. 

BABNBS, FAJVCOUBT, M. I)., 

Obstetric Physician to St. Thomas' Hospital, London. 

A Manual of Midwifery for Midwives and Medical Students. In one 
royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25. 



PABBY, JOHN S. 9 M. JD. 9 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. 
Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. 



TANNER ON PREGNANCY. Octavo, 490 pages, 4 colored plates, 16 cuts. Cloth, $4.25. 



30 



Lea Brothers & Oo.'s Publications — Midwfy., Dis. Cliildn, 



LEISMMAN, WILLIAM, M. D., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, 
$5.50 ; very handsome half Russia, raised bands, $6.00. 

The author is broad in his teachings, and dis- 
cusses briefly the comparative anatomy of the pel 
vis and the mobility of the pelvic articulations 
The second chapter is devoted especially to 
the study of the pelvis, while in the third the 



r 



female organs of generation are introduced, 
The structure and development of the ovum are 
admirably described. Then follow chapters upou 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the work are 
plain and pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 
To the American student the work before us 



must prove admirably adapted. Complete in all its 
parts, essentially modern in its teachings, and with 
demonstrations noted for clearness and precision, 
it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 
popular and is cordially recommended. — N. O. 
Med. and Surg. Journ., March, 1880. 

It has been well and carefully written. The 
views of the author are broad and liberal, and in- 
dicate a well-balanced judgment and matured 
mind. We observe no spirit of dogmatism, but 
the earnest teaching of the thoughtful observer 
and lover of true science. Take the volume as a 
whole, and it has few equals. — Maryland Medical 
Journal, Feb. 1880. 



LAWDIS, JBCEWBT G., A. M., 31. D., 

Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. 

The Management of Labor, and of the Lying-in Period. In one 

handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. 

tempt any one who should happen to commence 
the book to read it through. The author pre- 



The author has designed to place in the hands 
of the young practitioner a book in which he can 
find necessary information in an instant. As far 
as we can see, nothing is omitted. The advice is 
sound, and the proceedures are safe and practical. 
Centralblattfur Gynakologie, December 4, 1886. 

This is a book we can heartily recommend. 



supposes a theoretical knowledge of obstetrics, 
and has consistently excluded from this little 
work everything that is not of practical use in the 
lying-in room. We think that if it is as widely 
read as it deserves, it will do much to improve 



The author goes much more practically into the j obstetric practice in general. — New Orleans Medi- 
details of the management of labor than most cal and Surgical Journal, Mar. 188G. 
text-books, and is so readable throughout as to | 

SMITH, J. LEWIS, M. JD., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. 

A Treatise on the Diseases of Infancy and Childhood. New (sixth) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 887 
pages, with 40 illustrations. Cloth, $4.50 ; leather, $5.50 ; half Kussia, $6.00. 



Rarely does a pleasanter task fall to the lot of 
the bibliographer than to announce the appearance 
of a new edition of a medical classic like Prof. J. 
Lewis Smith's Treatise on the Diseases of Infancy 
and Childhood. For years it has stood high in the 
confidence of the profession, and with the addi- 
tions and alterations now made it may be said to 
be the best book in the language on the subject of 
which it treats. An examination of the text fully 
sustains the claims made in the preface, that "in 
preparing the sixth edition the author has revised 
the text to such an extent that a considerable 
part of the book may be considered new." If the 
young practitioner proposes to place in his library 
but one book on the diseases of children, we 
would unhesitatingly say, let that book be the one 
which is the subject of this notice. — The American 
Journal of the Medical Sciences, April, 1886. 

No better work on children's diseases could be 
placed in the hands of the student, containing, as 
it does, a very complete account of the symptoms 
and pathology of the diseases of early life, and 
possessing the further advantage, in* which it 



stands alone amongst other works on its subject, 
of recommending treatment in accordance with 
the most recent therapeutical views.— British and 
Foreign Medico-Chirurgical Review. 

It is a pleasure to the busy practitioner — inter- 
ested in the advancement of his profession — to 
meet, fresh from the hands of its author, a medi- 
cal classic such as Smith on Diseases of Children. 
Those familiar with former editions of the work 
will readily recognize the painstaking with which 
this revision has been made. Many of the articles 
have been entirely rewritten. The whole work is 
enriched with a research and reasoning which 
plainly show that the author has spared neither 
time nor labor in bringing it to its present ap- 
proach towards perfection. The extended table of 
contents and the well-prepared index will enable 
the busy practitioner to reach readily and quickly 
for reference the various subjects treated of in the 
body of the work, and even those who are familiar 
with former editions will find the improvements 
in the present richly worth the cost of the work.— 
Atlanta Medical and Surgical Journal, Dec. 1880. 



OWEJS T , EDMUND, 31 B., F. JR.. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. In one 12mo. volume of 525 pages, with 4 
chromo- lithographic plates and 85 woodcuts. Cloth, $2. See Series of Clinical Manuals, 
page 4. 

One is immediately struck on reading this book 
with its agreeable style and the evidence it every- 
where presents of the practical familiarity of its 
author with his subject. The book may be i 



honestly recommended to both students and 
practitioners. It is full of sound information, 
pleasantly given.— Annals of Surgery, May, 1886. 



WEST, CHAMLES, 31. I)., 

Physician to the Hospital for Sick Children, London, etc. 

On Some Disorders of the Nervous System in Childhood. 
12mo. volume of 127 pages. Cloth, $1.00. 



In one small 



WEST'S LECTURES ON THE DISEASES OF IN- 
FANCY AND CHILDHOOD. In one octavo vol. 
CCNDIE'S PRACTICAL TREATISE ON THE 



DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
779 pages. Cloth, $5.25 ; leather, $6.25.$ 



Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 



31 



TIDY, CHARLES MEYMOTT, 31. B., F. C. S., 

Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. 
Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Eape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
Cloth, $6.00 ; leather, $7.00. 

tables of cases appended to each division of the 
subject must have cost the author a prodigious 
amouni of labor and research, but they constitute 
one of the most valuable features of the book, 
especially for reference in medico-legal trials. — 
American Journal of the Medical Sciences, April, 1884. 



The satisfaction expressed with the first portion 
of this work is in no wise lessened by a perusal of 
the second volume. We find it characterized by 
the same fulness of detail and clearness of ex- 
pression which we had occasion so highly to com- 
mend in our former notice, and which render it so 
valuable to the medical jurist. The copious 



TAYLOR, ALFRED 8., M. D., 

Lecturer on Medical Jurisprudence and Chemistry in Ghuy's Hospital, London. 

A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by J ohn J. Reese, M. D., Professor 
of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one 
large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00 ; half 
Bussia, raised bands, $6.50. 



•'-The American editions of this standard manual 
have for a long time laid claim to the attention of 
the profession ia this country; and the eighth 
comes before us as embodying the latest thoughts 
and emendations of Dr. Taylor upon the subject 
to which he devoted his life with an assiduity and 
success which made him facile princeps among 
English writers on medical jurisprudence. Both 
the author and the book have made a mark too 
deep to be affected by criticism, whether it be 
censure or praise. In this case, however, we should 



only have to seek for laudatory terms.— American 
Journal of the Medical Sciences, Jan. 1881. 

This celebrated work has been the standard au- 
thority in its department for thirty-seven years, 
both in England and America, in both the profes- 
sions which it concerns, and it is improbable that 
it will be superseded in many years. The work is 
simply indispensable to every physician, and nearly 
so to every liberally-educated lawyer, and we 
heartily commend the present edition to both pro- 
fessions.— Albany Law Journal, March 26, 1881. 



By the Same Author. 

The Principles and Practice of Medical Jurisprudence. Third edition. 
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; 
leather, $12. 



For years Dr. Taylor was the highest authority 
in Eogland upon the subject to which he gave 
especial attention. His experience was vast, his 
judgment excellent, and his skill beyond cavil. It 
is therefore well that the work of one who, as Dr. 
Stevenson says, had an "enormous grasp of all 



matters connected with the subject," should be 
brought up to the present day and continued in 
its authoritative position. To accomplish this re- 
sult Dr. Stevenson has subjected it to most careful 
editing, bringing it well up to the times.— Ameri- 
can Journal of the Medical Sciences, Jan. 1884. 



By the Same Author. 

Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 783 
pages. Cloth, $5.50 ; leather, $6.50. 

PEPPER, AUGUSTUS J., M. 8., M. B., F. B. C. 8., 

Examiner in Forensic Medicine at the University of London. 
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students' 
Series of Manuals, page 4. 

LEA, HENRY C. 

Superstition and Force : Essays on The Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 
handsome royal 12mo. volume of 552 pages. Cloth, $2.50. 

This valuable work is in reality a history of civ- 
ilization as interpreted by the progress of jurispru- 
In " Superstition and Force " we have a 



This valuable work is in reality a history of civ 

izatio 
dence. 

philosophic survey of the long period intervening 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 



should not be most carefully studied ; and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of so- 
cial science. — Westminster Review, Jan. 1880. 



By the Same Author. 
Studies in Church History. The Rise of the Temporal Power- 



eflt of Clergy— Excommunication 
octavo volume of 605 pages. Cloth, $2.50. 

The author is pre-eminently a scholar. He takes 
up every topic allied with the leading theme, and 
traces it out to the minutest detail with a wealth 
of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary. In no 
other single volume is the development of the 



-Ben- 



New edition. In one very handsome royal 



primitive church traced with so much clearness, 
and with so definite a perception of complex or 
conflicting sources. The fifty pages on the growth 
of the papacy, for instance, are admirable for con- 
ciseness and freedom from prejudice. — Boston 
Traveller, May 3, 1883. 



Allen's Anatomy .... 

American Journal of the Medical Sciences 

American Systems of Gynecology . 

American System of Practical Medicine . 

An American System of Dentistry 

♦Ashhurst's Surgery .... 

Ashwell on Diseases of Women 

Attfield's Chemistry .... 

Ball on the Rectum and Anus 

Barker's Obstetrical and Clinical Essays, 

Barlow's Practice of Medicine 

Barnes' Midwifery . . 

♦Barnes on Diseases of Women 

Barnes' System of Obstetric Medicine 

Bartholow on Electricity 

Bartholow's New Remedies and their Uses 

Basham on Renal Disease's . 

Bell's Comparative Physiology and Anatomy 

Bellamy's Operative Surgery 

Bellamy's Surgical Anatomy 

Blandford on Insanity . ... 

Bloxam's Chemistry .... 

♦Bristowe's Practice of Medicine . 

Broadbent on the Pulse 

Browne on the Ophthalmoscope 

Browne on the Throat, Nose and Ear 

Bruce's Materia Medica and Therapeutics 

Brunton's Materia Medica and Therapeutics 

♦Bryant's Practice of Surges 

♦Bunistead on Venereal Diseases . 

♦Burnett on the Ear .... 

Butlin on the Tongue .... 

Carpenter on the Use and Abuse of Alcohol 

♦Carpenter's Human Physiology . 

Carter & Frost's Ophthalmic Surgery 

Century of American Medicine 

Chambers on Diet and Regimen 

Chapman's Human Physiology 

Charles' Physiological and Pathological Chem. 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen on the Throat .... 

Coleman's Dental Surgery 

Condie on Diseases of Children 

Cornil on Syphilis .... 

♦Cornil and Ranvier's Pathological Histology 

Cullerier's Atlas of Venereal Diseases 

Curnow's Medical Anatomy 

Dalton on the Circulation . 

♦Dalton's HumanPhysiology 

Davis' Clinical Lectures 

Draper's Medical Physics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

♦Dunglison's Medical Dictionary . 

Edes' Materia Medica and Therapeutics 

Edis on Diseases of Women . 

Ellis' Demonstrations of Anatomy 

Emmet's Gynecology 

♦Erichsen's System of Surgery 

Esmarch's Early Aid in Injuries and Accid'ts 

Farquharsou's Therapeutics and Mat. Med. 

Fenwick's Medical Diagnosis 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percussion 

Flint on Phthisis .... 

Flint on Physical Exploration of the LUngs 

Flint on Respiratory Organs 

Flint on the Heart .... 

Flint's Essays ... 

♦Flint's Practice of Medicine 

Folsom's Laws of TJ. S. on Custody of Insane 

Foster's Physiology .... 

♦Fothergiirs Handbook of Treatment . 

Fownes' Elementary Chemistry 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages . 

Galloway's Analysis 

Gibney's Orthopaedic Surgery 

Gould s Surgical Diagnosis . 

♦Gray's Anatomy ..... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

♦Gross' System of Surgery 

Hahershon on the Abdomen 

♦Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Hartshorne's Household Medicine 

Hermann's Experimental Pharmacology 

Hill on Syphilis ..... 

Hillier's Handbook of Skin Diseases 

Hoblyn's Medical Dictionary 

Hodge on Women .... 

Hodge's Obstetrics .... 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 



17 
29 
27 
29 
17 
11 
24 

4, 7 

4,20 
6 
19 
9 
14 

4,18 
23 
18 
11 
11 
21 
25 
23 

4,21 



14 
17 

8 
10 
28 
4,6 
10 

6 
19 
10 
13 
18 
24 
30 
25 
13 
25 
4, 6 

7 



♦Holmes' System of Surgery 

Horner's Anatomy and Histology . 

Hudson on Fever 

Hutchinson on Syphilis 

Hyde on the Diseases of the Skin . 

Jones (C. Handfield) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

Kaposi on Skin Diseases 

King's Manual of Obstetrics . 

Klein's Histology .... 

Land is on Labor .... 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence arid Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis 

Lehmann's Chemical Physiology . 

♦Leishman's Midwifery 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maisch's Organic Materia Medica . 

Marsh on the Joints 

May on Diseases of Women . 

Medical News . . 

Medical News Visiting List . 

Medical News Physicians' Ledger . 

Meigs on Childbed Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Mitchell's Nervous Diseases of Women . 

Morris on Diseases of the Kidney . 

Neill and Smith's Compendium of Med. Scl. 

Nettleship on Diseases of the Eye . 

Norris and Oliver on the Eye 

Owen on Diseases of Children 

♦Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery 

Pavy on Digestion and its Disorders 

Pepper's System of Medicine 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery . 

Playfair on Nerve Prostration and Hysteria 

♦Playiair's Midwifery . 

Politzer on the Ear and its Diseases 

Power's Human Physiology . 

Purdyon Bright's Disease and Allied Affections 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

^Reynolds' System of Medicine 

Richardson's' Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Compend of Anatomy 

Roberts' Principles and Practice of Surgery 

Robertson's Physiological Physics 

Ross on Nervous Diseases 

Savage on Insanity, including Hysteria . 

Schafer's Essentials of Histology, 

Schreiber on Massage . 

Seller on the Throat, Nose and Naso-Pharynx 

Series of Clinical Manuals . 

Simon's Manual of Chemistry 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

*Smith (J. Lewis) on Children . . 

Smith's Operative Surgery . 

StUle on Cholera .... 

*Stille & Maisch's National Dispensatory 

*Still6's Therapeutics and Materia Medica 

Stimson on Fractures and Dislocations, 

Stimson's Operative Surgery 

Stokes on Fever ..... 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor's Atlas of Venereal and Skin Diseases 

Taylor on Poisons .... 

♦Taylor's Medical Jurisprudence . 

Taylor's Prin. and Prac. of Med. Jurisprudence 

*Thomas on Diseases of Women . 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine .... 

Todd on Acute Diseases 

Treves' Manual of Surgery . 

Treves' Surgical Applied Anatomy 

Treves on Intestinal Obstruction . 

Tuke on the Influence of Mind on the Body 

Visiting List, The Medical News . 

Walshe on the Heart .... 

Watson's Practice of Physic . 

♦Wells on the Eye .... 

West on Diseases of Childhood 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Williams on Consumption . 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . 

W^inckel on Pathol, and Treatment of Childbed 

Wcihler's Organic Chemistry 

Woodhead's Practical Pathology . 

Year-Books of Treatment for 1886 and 1887 



4,13 



Books marked * are also bound in half Eussia. 



LEA BROTHERS & CO., Philadelphia, 



